Inspection on 02/10/07 for Ancaster Court

This inspection was carried out on 2nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ancaster Court 29/09/08

Ancaster Court 01/08/06

Ancaster Court 24/08/05

Ancaster Court 08/04/05

Ancaster Court 17/11/04

Ancaster Court 01/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ancaster Court 24 Hastings Road Bexhill On Sea East Sussex TN40 2HH Lead Inspector Elizabeth Baker Key Unannounced Inspection 2 October 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ancaster Court Address 24 Hastings Road Bexhill On Sea East Sussex TN40 2HH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01424-213532 01424 221925 sowerbya@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd Alison Sowerby Care Home 51 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (51) of places Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users that can be accommodated is fifty-one (51) The home may from time to time accommodate service users under the age of sixty-five on admission Up to twelve service users who have nursing needs may be admitted with the condition dementia 1st August 2006 Date of last inspection Brief Description of the Service: Ancaster Court has 51 registered beds that can be used to provide nursing care and admits people who are privately funded and those who are funded by Social Services. A secure unit on the second floor now provides separate accommodation for 12 of the 51 residents, requiring general nursing and dementia care. Ancaster Court is owned and managed by BUPA Care Homes Ltd. The bedrooms are found on three floors and an 8-person passenger lift accesses all accommodation used by residents. Four of the bedrooms are registered for double occupation, but only one of these is now used for shared occupancy. 16 bedrooms have en-suite facilities. Ancaster Court is a Victorian building that has been converted and adapted to its present use. It is located in a residential area approximately half a mile from Bexhill town centre, seafront and mainline train station. The home has a garden to the rear of the property. There is parking to the front of the home for approximately 15 vehicles. At 2 October 2007 fees ranged from £417 to £769 per week depending on the room to be occupied, funding arrangements and the assessed care needs of the individual. Additional costs are charged for chiropody, hairdressing, newspapers and magazines. The current range of activities includes bingo, quizzes, poetry club and PAT the dog visits. Holy Communion services take place on a monthly basis. A copy of the latest inspection report is kept in the ground floor lounge. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key unannounced visit to the home for the inspection period 2007/08. Link inspector Elizabeth Baker carried out the visit on 2 October 2007. The visit lasted just over nine hours. As well as visiting each floor, the visit consisted of talking with some residents and staff. Five residents, four visitors and two members of staff were interviewed in private. Verbal feedback was provided to the supernumerary Registered Nurse during the course of the morning visit and to the home manager at the end of the visit. At the time of compiling the report, in support of the visit, the Commission received survey forms and or comment cards about the service from six residents, two care managers and 12 relatives/advocates. At the Commission’s request the home manager completed and returned the home’s first Annual Quality Assurance Assessment (AQAA). Some of the information gathered from these sources has been incorporated into the report. At the time of the visit 43 residents requiring general nursing and or dementia care were residing at the home. What the service does well: What has improved since the last inspection? This was the inspector’s first inspection visit to the home so it was difficult to establish. However, the second floor has been refurbished to accommodate residents who now require general nursing and dementia care. The windows in a particular bedroom have been replaced making the room brighter. The occupant and visitors were pleased about this. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence including a site visit to the home. Prospective residents generally move into the home knowing their needs will be met. EVIDENCE: To inform prospective residents and or their advocates about the services and facilities provided at Ancaster Court, the provider has produced a Statement of Purpose supplemented by a colour brochure. However the Statement of Purpose is dependent on the reader having access to and understanding of some of the Provider’s policies and procedures as well as the Department of Health’s National Minimum Standards document Care Homes for Older People. To assist homes and providers in developing their Statement of Purpose the Commission published guidance in 2003. This is available from the Commission’s website and may assist the home in enhancing its current documents so that the Statement of Purpose reflects the home’s individuality in more detail. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 9 As part of the home’s admission process the home manager or her representative visit prospective residents in their current place of occupation to establish whether the home is suitable for their assessed needs. Where practicably possible prospective residents are invited to visit the home prior to a decision of admission being made. Where this is not possible advocates visit the home on their behalf. The home is not registered for intermediate care. Standard 6 is not applicable. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence including a site visit to the home. Although the health and personal care needs of residents are generally met, the new record system, when fully implemented, should provide a better audit trail of residents’ assessed needs and the care being provided. The current state of medicine records and storage facilities potentially places residents at risk. EVIDENCE: The provider has recently developed and is providing all its care homes with new care documentation. At the time of the visit the home had recently transferred to the new system. From the sample inspected care records contained Quest Individual Assessments, personal plans and a range supporting clinical and health assessments. The individual assessment document informs the carer as to what action they must take, for example if a plan identifies a particular risk assessment or chart is needed to monitor the effectiveness of the personal plan. However where this was the case some of the corresponding forms where either blank or incomplete. This included continence, pain and behaviour. The moving and handling assessment for one resident was unavailable. In one file there was evidence that a restraint form Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 11 had been completed for the use of a wheelchair safety belt. However there was no restraint forms for the use of an armchair safety belt or the provision of a pressure mat, both of which put further restrictions on the resident’s freedom of movement. For residents who require spectacles to improve their vision, good personal plan details were seen. Daily records are maintained. However these generally focused on the residents’ medical condition and did not provide a holistic picture of their quality of day experiences. Some practitioners record meaningless comments including “all care maintained”; “all due care planned”; “due medication given”; “settled and slept well”. This is contrary to Nursing and Midwifery Council’s guidance for record keeping. For skin integrity purposes and for the treatment of pressure sores, residents are provided with special pressure relief and or preventative equipment if there is an assessed need. However an airflow mattress seen in one room and an airflow cushion in another were not functioning. Both pieces of equipment were supposed to be in use. Each floor has its own room in which medicines are stored. The rooms are equipped with a range of store cupboards and all have a fridge for the storage of medicines, tubes of creams and drops requiring refrigeration. However the design of one of the fridges and the quantity of items currently being stored resulted in the items being kept muddled together and a number having sticky containers because of spillages and contact. Indeed the overall decorative and cluttered state of all three rooms was no conducive to a clinical environment expected in a home providing nursing care. The situation also prevents effective cleaning. Hand washing facilities are provided. However hot water from the hand wash-sink in one of the rooms was unavailable necessitating care staff to use the sink intended for medicine preparation purposes. A review of medication administration record (MAR) charts was undertaken. This indicated that some practitioners are not completing the charts as required. This includes inserting the code ‘O’ but without defining the reason why; not inserting the actual dose administered when variable dose medicine has been prescribed; changing the prescriber’s instructions without written details of the effective date and on whose authority the change occurred; and handwritten entries without signatures and countersignatures. The personal plan for one resident indicated that two types of emoluments were being applied to their pressure areas. However the corresponding MAR chart did not include these preparations. The MAR chart folders and plastic inserts were in the main grubby and sticky, placing residents potentially at risk of cross infection. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 12 Generally, residents indicated their privacy and dignity is maintained when care staff assist them with their personal care. Care staff are aware of the need to ensure doors are closed when providing this care. However they do not always wait for an answer before entering bedrooms, resulting in one particular resident feeling embarrassed. The new care documentation requires staff to obtain details of residents’ spiritual and cultural wishes in the event of death and dying. Work has commenced on obtaining and recording this sensitive but important aspect of care information. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents who use the service experience good outcomes. This judgement has been made using a range of evidence including a site visit to the home. On the whole residents are able to spend their time as they wish to. The meals at the home are good offering both choice and variety and catering for special diets. EVIDENCE: The home’s flexible routines enable residents to choose how to spend their time. While some enjoy group activities, others prefer their own company. The returned AQAA states that there is now a dedicated activities organiser for the dementia unit on the top floor who provides therapeutic activities on a one to one basis. Indeed one resident was receiving one to one care at the time of the visit and appeared re-assured by this support. Some residents are supported in going to the nearby town and enjoy this. Holy Communion services are organised at the home on a monthly basis and lay people from other religious denominations visit residents at the home as required. Visitors are welcomed at any time and are offered refreshments. The new care documentation requires staff to obtain details of the residents’ former life experiences. This is a useful document and should help the home ensure its current range and availability of activities meets the needs, abilities and expectations of its current residents. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 14 Residents spoke positively about their meals with comments including “remarkably good food”; “food quite good and get a choice” and “food very good and tasty”. Special diets are catered for where there is an assessed need. Residents have the choice to eat their meals in one of the home’s dining rooms or in the privacy of their bedrooms, if they prefer. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence including a site visit to the home. Systems are in place for residents and others to make a complaint. However the provider’s procedures are not always followed which may prevent an up to date record of all types of complaints being readily available. EVIDENCE: The home has a complaints procedure, which is displayed in the foyer. A record book of formal complaints and responses is maintained. However it was identified on this visit that details of verbal complaints are not recorded in this book but are recorded in individual records and or the communications book. Some respondents to the announcement of this visit indicated there had been times when they had made a complaint to the home manager. The home’s complaints record book did not contain these. Having a central record of all types of complaints and niggles provides a more effective way of auditing trends for quality assurance purposes. The home has policies and procedures to follow in the event of allegations of abuse being made. However the contact details of the Commission are out of date. It was also identified that the home’s copy of the County’s policies are procedures are out of date. The home must obtain an up to date copy to ensure its own policies and procedures interlink with those of the County’s. Although the training matrix supplied at the visit indicated only one member of staff had received prevention of vulnerable adult training, staff interviewed Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 16 demonstrated appropriately the action they would take if they had a suspicion of abuse. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence including a site visit to the home. For equality purposes, more investment should be available to improve the first and ground floors, making the whole home a more comfortable place for all residents to live in. The standard of cleaning needs to improve to minimise potential cross infection risks to residents. EVIDENCE: Since the last visit the second floor has become a secure environment for residents with nursing and dementia care needs. The environment was refurbished to support its registration application. However there have been no fundamental changes to the rest of the home since a major refurbishment in 1994. With the passage of time and continuous wear and tear, some parts of the ground and first floors are looking tired and worn. Doors and doorframes have been badly scored, some bedroom carpets are stained and a number of chairs were dirty. The cluttered state of the laundry and sluice Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 18 rooms precludes effective cleaning to minimise cross infections. Some bedrooms have en suite rooms. However one was being used to store excess nursing sundries, precluding effective cleaning as well as preventing the intended use of the room. The plughole in the washbasin was partly blocked. While acknowledging the visit started early, there was underlying odour prevailing throughout the entire visit in most areas, the cause of which should be investigated and action taken to eradicate it. Respondents comments in support of this visit included “[the home] gets whiffy”; “staff do not always clear up properly when there has been a spillage” and “staff do not always Hoover properly particularly when things get dropped on the carpets”. Sadly according to the training matrix supplied, only two members of staff are recorded as having received infection control training since the last inspection. An officer of the local environmental health department carried out an inspection of the home’s kitchen. This resulted in a number of requirements. The home manager said the matters had been put right. Some residents like to keep their bedroom doors open to enable them to see people coming and going, as well as being able to go in and out of their rooms in a safe and independent manner. For residents to do this, some bedroom doors have been fitted magnetic closures, which are connected to the home’s fire safety system so they close automatically. Indeed a test of this was carried out during the visit. Door guards were seen on other bedroom doors. However other bedroom doors were propped open by rubber doorstops and in one case a cord. These are not approved fire safety methods and the practice must be discontinued. The home has a range of lifting and moving equipment so residents can be safely transferred. The home also has a range of pressure relief and preventative equipment. The equipment is provided to residents’ on an needs assessed basis. As stated previously, it was of a concern to see that an airflow mattress and wheelchair cushion were not being used appropriately, placing the residents potentially at risk. During the visit it was noted that not all corridors are fitted with handrails to support residents walking around the home independently. Residents have access to gardens and some said how much they enjoy using them. To enhance the current provision the home successfully applied for and was granted funds. When weather permits, residents will be involved in the planting of raised beds and sensory garden so the project can be completed. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence including a site visit to the home. Staff are enthusiastic about their roles and enjoy working at the home. However residents are potentially at risk because vetting checks are not always robustly followed. EVIDENCE: As well as care staff, staff are employed for cooking, activities, cleaning, laundry, administration, maintenance and gardening. Staff rotas are maintained and indicate the home is staffed 24 hours a day. The manager reported that care staffing levels have increased to reflect the needs of the current residents, as well as to take account of the geography of the building. Despite this some residents and respondents are of the view that there are care staff shortages. The returned AQAA document indicates that 41 of unregistered care staff are currently trained in NVQ level II or above. Other staff are now working towards this. To reflect the home’s registration variation a Registered Mental Health Nurse was employed to lead the dementia care unit. However the nurse has now left. The home is now recruiting for a suitably qualified replacement. The training matrix supplied indicates that staff have received training in topics covering dementia awareness, food hygiene, bed rails, moving and handling, fire training and managing violence and aggression and Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 20 two staff have received infection control training. Two of the home’s registered general nurses have completed a six-month Quality in Dementia Care training course. A newly appointed member of staff spoke enthusiastically about commencing their NVQ care training and expressed a desire to eventually do nurse training. New care staff are required to undertake an in-depth induction, which follows the Skills for Care training programme. Systems are in place for the recruitment and appointment of staff. The procedures require new staff to be appropriately vetted before they actually commence work at the home. A review of two application forms identified that there was no employment history stated in one case. And in the other case there was no recorded evidence employment gaps had been investigated. This information is required by regulation. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38. Residents who use the service experience adequate outcomes. This judgement has been made using a range of evidence including a site visit to the home. Generally management of the home is satisfactory and the manager has a good understanding of what needs to be done to improve the service. However some of the residents are potentially at risk because records are not always well managed. EVIDENCE: The home manager is a Registered Nurse, has been the home manager of Ancaster Court for five years and has successfully attained the Registered Managers Award. Residents, visitors and staff spoke openly about their experiences at the home. Meetings are facilitated for residents, relatives and staff to meet regularly so their views and opinions about the service can be expressed and listened to. The provider organises annual satisfaction surveys and when analysed the Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 22 results are published and made available. Indeed a copy of the last survey results is kept in the ground floor lounge, for easy access. The provider has recently provided its care homes with updated policies and procedures manuals to reflect current practice. These are available for staff to access. However a memo dated 1998 for maintaining syringe pump drivers was seen in one of the medication administration record chart files. There was no recorded evidence it had been regularly updated to ensure the instructions were still relevant. The home maintains personal monies for some residents. Records of transactions are kept. Receipts are obtained for services provided or items obtained on behalf of residents. Monies are held in a separate interest bearing account. BUPA has devised a system to distribute interest proportionately. The home sometimes retains small items of importance on behalf of residents and records of the arrangement are kept. Although care staff receive regular supervision, it has been the home’s practice to provide notes of one to one sessions to care assistants only. This may present difficulties if the home manager needed to provide evidence for disciplinary purposes, with regard to registered nurses. Accident records are maintained to enable the provider to monitor trends and take appropriate action where this is identified. As stated previously within the report, not all records relating to residents’ wellbeing and are completed as required, potentially placing some residents at risk. During the visit it transpired there had been an infectious disease incident affecting residents’ welfare. The home was required by regulation to inform the Commission about this. This was not done. The area’s Health Protection Agency should also have been informed about this. The returned AQAA document indicates the home’s equipment is regularly serviced and maintained. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 2 Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1) Requirement The statement of purpose must be expanded to provide the reader with full details of the services and facilities provided at Ancaster Court Pressure relief equipment must be kept in working order when being used by residents Recorded evidence must be available when action restricting a resident’s freedom of movement, for their safety, has been done, including restraint forms. This should include input from the resident and advocates. Storage arrangements must be reviewed to ensure medicines are kept hygienically and in accordance with the manufacturers instructions Medication administration record charts must include the actual dose administered and be completed as the chart requires Full details of dose changes to the prescriber’s directions must be clearly recorded on the medication administration record chart. DS0000013953.V348273.R01.S.doc Timescale for action 31/01/08 2 3 OP8 OP8 16(1)(2) (c) 17(1)a 15/10/07 31/10/07 4 OP9 13(2) 31/10/07 5 OP9 13(2) 15/10/07 6 OP9 13(2) 15/10/07 Ancaster Court Version 5.2 Page 25 7 8 9 10 OP9 OP19 OP19 OP26 13(2) 23(2) 23(4) 13(3) 16 19(1)(b) Sch 2 11 OP29 12 13 OP37 OP38 17 37 Medicines must be administered as per the prescriber’s instructions All areas used by residents must be kept in a good decorative state That approved measures are taken to ensure the protection of all residents in the case of fire. The standard of cleaning throughout the home must improve to minimise cross infection risks. Full employment histories must be obtained for all staff employed to work at the care home; any employment gaps must be investigated All records relating to residents must be up to date and complete The commission must be informed of all accidents, injuries and incidents of illness or communicable disease affecting the welfare of residents. 15/10/07 31/10/07 31/10/07 31/10/07 30/11/07 31/10/07 15/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP8 OP16 OP18 OP18 OP22 OP22 Good Practice Recommendations Clinical risk assessments and charts must be properly completed It is strongly recommended that details of all types of complaints and niggles are recorded in a way which provides a quick and effective way of monitoring trends. All staff must receive adult protection training. The home must obtain a copy of the County’s current Adult Protection Procedures. It is strongly recommended that hand/grab rails be provided in all areas, which would most benefit residents. Excess nursing aids and sundries must not be stored in DS0000013953.V348273.R01.S.doc Version 5.2 Page 26 Ancaster Court 7 8 9 9 OP26 OP28 OP33 OP36 resident’s en suite toilets; It is strongly recommended that the cause of the odour is identified and action taken to address the problem 50 of untrained care staff must attain NVQ level II care. Notices and directions should be regularly reviewed to ensure staff work in accordance with good practice and regulation It is strongly recommended that all staff supervision sessions be recorded, for evidence purposes. Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ancaster Court DS0000013953.V348273.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!