Inspection on 24/08/05 for Ancaster Court

This inspection was carried out on 24th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 02/10/07

Ancaster Court 01/08/06

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 Melanie Freeman Announced 24 August 2005 10:00 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 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 H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ancaster Court Address 24 Hastings Road Bexhill on Sea East Sussex TN40 2HH 01424 213532 01424 221925 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Ltd Alison Sowerby CRH 51 Category(ies) of Old age, not falling within any other category registration, with number (OP) 51 of places Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum service users to be accommodated is 51. 2. That the care home can provide nursing/residential care to older people aged 65 or over on admission. 3. The service can provide up to 51 nursing places and 3 social care places. Date of last inspection 8 April 2005 Brief Description of the Service: Ancaster Court is a Victorian building that has been converted and adapted to its present use. It is located in a residential area approximately 1/2 mile from Bexhill town centre, seafront and mailine train station. The home has a garden to the rear of the property where residents can sit weather permitting. There is parking to the front of the home for approximately 15 vehicles. Ancaster Court has 51 registered beds that can be used to provide general nursing care and admits people who are privately funded and those who are funded by Social Services. The bedrooms are found on three floors and a passesnger lift provides level access throughout the home. 4 of the bedrooms can be used for sharing and 16 have en-suite facilities. Ancaster Court is owned and managed by BUPA Care Homes Ltd. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Ancaster Court Nursing Home will be referred to as ‘residents’. The report should be read in conjunction with the report of the inspection that took place on 8 April 2005 for an overview of the standards that were not reviewed at this inspection. This was an unannounced inspection carried out between the hours of 14.00 and 18.00. The home manager was on duty and was able to contribute to the inspection process. The inspector was able to spend time with residents and their visitors in their private rooms. This contact included speaking to 11 residents and 4 visitors. . The inspector also observed staff working and spoke to staff informally. The care documentation is retained on three separate floors and the Inspector reviewed 2 from each, along with staff training records. The care documentation pertaining to 4 residents were reviewed in depth. The inspector toured the home and was able to review the facilities and standard of cleanliness. What the service does well: All prospective residents are given full the chance to visit the home and to check out the services before they agree to move to the home. Care documentation is clear and used to give guidelines to care staff on how to care for an individual. Feedback from residents and visitors confirmed that they were satisfied with the care that they received. Although the home is large the individual and communal space provided is homely and well maintained. Visiting is encouraged and the home works hard on maintaining links with the community. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 Information on the home is available to people to inform their choice. Pre-admission procedures encourage prospective residents and their representatives to visit the home to assess the quality and facilities. EVIDENCE: The home provides a statement of purpose and service users guide that is presented in a folder located in the communal lounge and in resident’s bedrooms. An examination of the documents confirmed that these need to be updated in some areas. On the whole the information provided was full and comprehensive. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 9 Prospective residents and their relatives are invited to visit the home prior to admission as part of the admission process. Overnight stays and day visits to include meals are also available. There is a monthly trial period for both residents and home to ensure suitability and this is confirmed in the terms and conditions of residency. The home manager said that she takes pictures of the home and the possible room to be occupied to the prospective service user if they are unable to visit the home themselves. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 Individual plans of care recording the needs of residents with their involvement when possible are maintained and are up to date. The homes procedures for safe administration of medicines are not being followed which may lead to unsafe practice in the home. EVIDENCE: The care documentation was found to be full and based on a comprehensive needs assessment. The care was being reviewed regularly and monthly reviews were recorded, this review included a re-assessment of the resident’s vital signs and weight. The home has a system to evidence residents or their representative’s involvement in the planning and delivery of care within the care documentation. A visitor spoken to during the inspection confirmed that they felt involved and kept up to date in respect of their sister’s care. During the inspection the inspector observed staff administering medicines and although the home has appropriate policies and procedures for the safe administration of medicines these were not being followed. Medicines had been Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 11 administered and the medicine charts had not been signed at the time of administration. This concern was identified to the home manager at the time of this inspection. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 and 15 The provision of meals has been improved and now provides a good standard and quality. Residents are enabled in maintaining links with people from outside the home and to maintain their own autonomy. EVIDENCE: Visiting is encouraged and visitors spoken to confirmed that they were always welcomed and feel able to visit whenever they wanted to. The home has recently held a dog show that was very well supported by the local community and enjoyed by residents. Residents have access to the home’s mobile phone or they can have their own separate telephone line. During the inspection residents spoken said that they were able to choose how they spent their day and could go to bed and get up when they wanted. The inspector noted that many of the residents went to bed early and the home manager advised that this was at their request. Discussion took place around the need to record these choices in the care documentation. During the inspection it was noted that residents are able to personalise their own rooms, some looking very individual. Since the last inspection the food provision has been reviewed including new menus and it was clear from the feedback received from residents that the food has improved. The manager explained that this was an ongoing process Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 13 but comments received at residents meeting, which the cook attends, were positive. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18 Procedures and practices in the home ensure that complaints made and any allegation or suspicion of adult abuse, are managed appropriately. Resident’s civic rights are promoted by the staff and manager. EVIDENCE: The home has a clear complaints procedure and records seen confirmed that complaints are dealt with appropriately. These procedures include an easily accessible complaint form, which can be used by residents and visitors. One visitor spoken to said that she had raised some concerns with the management of the home and that these had been addressed appropriately. The home manager confirmed that all residents have a named relative or solicitor to deal with their affairs and the home has established links with Age Concern to provide advocacy services if needed. The home has an adult protection procedure that has been adapted to ensure local guidelines are followed. Staff training includes training on adult protection issues. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23 and 26 The home provides service users with a comfortable environment that is well decorated. The cleaning standard in some areas remains poor and infection control practice may be putting residents at risk. EVIDENCE: During the tour of the home it was clear that the home continues to be subject to an on going redecoration programme. Ancaster Court provides a well-maintained environment that provides individual space for each resident within one of the 43 single rooms or one of the 4 shared rooms. There is a lounge, dining room and sun lounge on the ground floor, and an additional lounge/dining room on the second floor, these areas are used by all residents as there is level access to all areas of the home and a passenger lift serves all floors. Ancaster Court has attractive gardens and access to these is provided with a ramp. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 16 The inspector again noted at this inspection that some areas in the home were not clean, this included dirty bed frames, dirty bins that had not been provided with plastic liners and used commode pots being left in communal bathing areas along with a dirty commode. Cleaning schedules were not available at the time of the inspection. The inspector was concerned that the correct infection control practice were not being followed as she noted dressings in a communal bin, dirty commode pots as identified above, dirty commodes, dirty toilet brushes and a urinal and plastic jug being stored in a communal bathroom. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 and 30 The recruitment practice was full and robust ensuring suitable staff are employed. Staff training is still being developed and does not fully demonstrate that staff are trained to do their jobs. EVIDENCE: There were 41 resident living in Ancaster Court at the time of this inspection. During the inspection 3 care staff recruitment files were examined and were found to be complete. The staff training records remain incomplete and do not record all the training provided. Evidence that induction had been completed and that foundation training had been established were not full. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 Systems are in place to safeguard resident’s finances. In general good health and safety procedures are in place to ensure staff and resident’s safety. EVIDENCE: All residents have the opportunity to manage their own money and a locked facility is provided in each room. There is a strict procedure in place regarding documentation of ‘pocket money’ and receipts are required for every transaction. Pension books are not held at the home but at the head office. During the inspection it was noted that some bedroom doors were being wedged open this practice needs to be reviewed with the local fire brigade to ensure fire safety systems are not being compromised. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x 3 x x 2 Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 20 No 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. 2. Standard 1 9 Regulation 6(a) 13(2) Requirement That the statement of purpose is reviewed and revised as necessary. That the homes policy and procedure for the safe admisitration of medicines is adhered to at all times. That clear effective infection control practice is followed at all times. That all areas of the home are cleaned routinely.(outstanding since last inspection) That all staff receive induction and foundation training which meets National Training Organisation (NTO) specifications within the time limits specified in NMS 30.2 & 30.3 (outstanding since last 2 inspections). That the use of door wedges is reviewed in consultation with the fire brigade as a priority. Timescale for action 1.10.05 20.9.05 3. 4. 5. 26 26 30 13(3) 16(2)(e) 18(1)c) 20.9.05 1.10.05 1.12.05 6. 38 23(4) 20.9.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 21 No. 1. 2. Refer to Standard 14 22 Good Practice Recommendations That residents choices on how to spend their day is recorded in their care documentation. That an assessment of the premises and facilities should be undertaken by a qualified Occupational Therapist, to advise on the suitability of disability equipment and environmental adaptations. Ancaster Court H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT National Enquiry Line: 0845 015 0120 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 H59-H10 S13953 Ancaster Court V237828 240805 Stage 4.doc Version 1.40 Page 23 - 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. 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