Inspection on 16/02/07 for Anna Victoria Nursing Home

This inspection was carried out on 16th February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Anna Victoria Nursing Home 10/08/09

Anna Victoria Nursing Home 22/05/09

Anna Victoria Nursing Home 26/01/09

Anna Victoria Nursing Home 21/02/06

Anna Victoria Nursing Home 07/10/05

Anna Victoria Nursing Home 17/01/05

Anna Victoria Nursing Home 07/09/04

Anna Victoria Nursing Home 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Anna Victoria Nursing Home Peace Haven Pole Barn Lane Frinton On Sea Essex CO13 9NH Lead Inspector Diana Green Unannounced Inspection 16th February 2007 10:30 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 Anna Victoria Nursing Home DS0000015319.V330920.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. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anna Victoria Nursing Home Address Peace Haven Pole Barn Lane Frinton On Sea Essex CO13 9NH 01255 675609 01255 673791 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) Anna Victoria Nursing Home Mrs Carol Nunn Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (2), Physical disability over 65 years of age of places (28), Terminally ill over 65 years of age (2) Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 28 persons) Persons of either sex, aged 65 years and over, who require general palliative care (not to exceed 2 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 2 persons) 21st February 2006 Date of last inspection Brief Description of the Service: Anna Victoria provides nursing and personal care with accommodation for up to 28 older people. The home is also registered to care for service users with a terminal illness. Anna Victoria is owned by a charitable organisation, named Anna Victoria Nursing Home. The home is founded on Christian principles and a weekly church service and monthly prayer meetings are held. The home is located within walking distance of Frinton-on-Sea High Street, Essex. The home is a two-storey building that was purpose built and first opened in 1992. There are 28 single en-suite bedrooms on two floors that are accessible by stairs and a lift. Four rooms have screening that can be opened to provide two shared rooms. The home offers large communal areas. The rear of the home has an enclosed well-maintained garden and is accessible by ramps. The open plan sensory garden to the front of the premises provides a pleasant outlook from the home. The home has a visitors’ room and overnight accommodation can be arranged. There is a loop system installed at the home for the benefit of those with a hearing impairment. The home is accessible by car and the nearest railway station is nearby. Parking is available for staff and visitors in the large car park located to the front of the home. The fees range from: £393.08 -£682.59 per week Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 19/02/07 Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 10/02/07 lasting 4 hours. The inspection process included: discussions with the deputy manager, the cook, the laundry assistant, the activities coordinator, five residents, six care staff, five visitors and feedback from health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twentysix standards were covered, four requirements and three recommendations made. The deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Action had been taken to ensure that medication records for controlled drugs included the name and address of the supplier on receipt and discharge. An annual plan had been developed for the home. Anna Victoria is accredited with Anglia Ruskin University to accept student nurse placements and the annual review had been undertaken to enable this to continue. A Macmillan nurse had provided training, to enable the home to introduce the Liverpool Care Pathway for residents receiving end of life/palliative care. Anna Victoria Nursing Home DS0000015319.V330920.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. Anna Victoria Nursing Home DS0000015319.V330920.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 Anna Victoria Nursing Home DS0000015319.V330920.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, 5, 6 Quality in this outcome area is good. Residents were well informed, had their needs assessed and were assured that they could be met prior to moving in to the home. The service does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide were available to prospective residents and were displayed in the entrance of the home together with the previous inspection report. The statement of purpose included the aims and objectives of the home but did not include the end of life/palliative care service that was also offered at the home. The statement of purpose also referred to Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 9 the home being registered for two palliative care beds, which is no longer a requirement. The files of four residents were seen and each one had a pre-admission assessment dated before the resident was admitted to the home and signed by the manager or deputy manager. The assessments covered all areas of care needs including personal care, mobility, continence, nutrition and medication. New residents were offered a trial period of one calendar month provided to ensure they were comfortable in the home and it met their expectations. Visitors spoken with say they were welcome to visit the home before their relative was admitted. One confirmed that the manager had visited the hospital to assess their relative, providing leaflets and made numerous telephone calls: overall they felt the process of admission had been very well prepared. They also said they chose the home because it was well renowned locally as a good nursing home. Anna Victoria Nursing Home DS0000015319.V330920.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, 10, 11 Quality in this outcome area is good. The health and personal care needs of residents are well met through robust care planning that is closely monitored and regularly reviewed. Residents’ privacy and dignity is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents had a care plan that had been agreed with them or their relative. The files of four residents were inspected. All contained risk assessments for daily activities undertaken by the residents. These included risk assessment for falls, moving and handling, waterlow (skin assessment) and use of bed rails. Regular weight monitoring was recorded with evidence that action was taken to provide soft diets and supplements as needed. Daily records were detailed and showed how residents were and what care had been given to them and confirmed their relatives were kept informed on all aspects care. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 11 Relatives spoken with said that they were kept well informed on any changes and were satisfied with the communication. There were two GP practices who supported the home and visited twice weekly and on request. The records contained contact details of health and social care professionals involved with the care of the resident. These included the GP, social worker, chiropodist, practice nurse, tissue viability nurse and physiotherapist. Residents received annual eye tests at the home and a visiting dentist attended as needed. Records demonstrated appropriate and prompt referral and good monitoring of health care needs. The home had a policy and procedures for the safe administration of medicines. However these needed to be reviewed to remove reference to the local health authority. Guidance published by the Royal Pharmaceutical Society of Great Britain (RPSGB) was also available for staff guidance. Medication was stored in two trolleys that were secured to the wall of the locked clinical room. There was a controlled drug cupboard and a separate drug fridge. Systems for monitoring daily temperatures were in place. Medication was supplied by a local pharmacy in a monitored dosage system and checked against residents’ prescriptions by a registered nurse. The home had a contract with a licensed contractor for the disposal of medication as required for a care home with nursing. Stock levels were at an acceptable level. Records made since the previous inspection confirmed that the full name and address of the supplier was recorded in the dedicated register. Medicines administration records were generally well recorded, however codes were not always used to record the reason for omission. Updated photographs of each resident were held with their MAR sheet. Registered nurses administered all medication: a list of their signatures and initials being maintained for checking against. Systems were also in place to ensure NMC Pin numbers were recorded and checked to ensure they were current. Manufacturers medication information was provided for individual medicines as indicated as good practice. No residents were selfmedicating but lockable facilities were available for safe storage. Residents spoken with said that staff were respectful and kind towards them, preserving their privacy and dignity when providing personal care. Relatives spoken with said they felt that privacy was respected and they were welcomed into the home at anytime and could see their loved one in private. One said that “staff are wonderful”; they are very flexible and ask what you want to be called”. The home provided care for people at the end of their life and those needing palliative care. The manager and staff had additional training and skills in care of the dying and there were good links with specialist nurses. A Macmillan Nurse had recently provided training for the home to introduce end of life care tools as part of the care planning process. One relative spoken with, who had recently lost their loved one at the home, praised the care given during the last weeks of their life. They said that the home had “the right ethos”; “the Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 12 care was excellent”; and their relative “felt happy here”. They also said that staff were very good, very kind and always acted ‘properly’ and this was evident at whatever time they visited. Policies and procedures on end of life /palliative care needed updating to reflect the good standard of care that was evidently being provided at the home. Anna Victoria Nursing Home DS0000015319.V330920.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, 15 Quality in this outcome area is good. The social and therapeutic activities offered at the home met residents’ cultural needs and expectations and enhanced their daily lives. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activities coordinator was employed full-time during weekdays. There was a programme of activities on display that included regular prayer meetings, communion services and entertainment. Residents’ preferences were recorded together with a life history on admission and activities arranged to meet their needs. Seven residents were taking part in a word/board game in the morning. Sheets were provided in large print and each resident was encouraged to use their own pen during the game. Entertainment was provided by a vocalist/comedian during the afternoon with residents, staff and visitors taking part in a very lively session. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 14 The statement of purpose and service users’ guide provided information on the home’s visiting arrangements. Visiting was open access and four visitors spoken with said they were welcomed into the home at anytime. One visitor said they were invited to have lunch at the home, although their relative was no longer there. Links with the local community included prayer groups and volunteers. Local schools and choir groups visited the home during the festive season. Four visitors spoken with said they were able to visit at anytime and found the home and staff very friendly and welcoming. All residents had a relative or representative to act on their behalf. Information was also made available to residents with regard to accessing advocacy services, if required. Some residents’ rooms had personal items of furniture and pictures that they had been enabled to bring into the home. Residents were observed to have their meals in their own rooms, or the dining room as they chose. Those spoken with said they could choose when they got up and go to bed and whether to take part in activities as they wished. The menu of the day was displayed on the notice board. Three meals were provided daily with one main meal at lunchtime and alternative choices offered. The lunch comprised a choice of fillet of salmon with hollandaise sauce, mashed potato, spinach and grilled tomatoes or alternative choices of scampi, chips and peas, fried plaice, chips and peas or lasagne chips and peas. Deserts comprised steamed spotted dick and custard, strawberries with ice cream or cream or fruit cocktail and cream. Lunch was served in the dining room and in residents’ rooms as they chose. Nutritional assessments were undertaken on admission and a list of residents’ likes and dislikes held in the kitchen. The record confirmed that nutritional intake was monitored and weights recorded and action taken as necessary. Residents said they enjoyed the food and had plenty to eat and drink. Food stocks were appropriately stored and were plentiful. The kitchen was clean and well organised with appropriate systems in place. Anna Victoria Nursing Home DS0000015319.V330920.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, 18 Quality in this outcome area is good. Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included timescales within which complainants can expect a response. This needed review to refer to social services as the lead agency to investigate complaints following the provider. There had been no complaints made since the last inspection. The procedure was included in the statement of purpose and displayed in the home for resident and representatives’ information. Residents spoken with said they had no complaints and feedback received from visitors was very positive about the staff and care provided. The home had a policy and procedures for the protection of vulnerable adults and whistle blowing. The manager had previously attended a training workshop held by Essex Vulnerable Adults Protection Committee and had obtained guidance books for distribution to all staff. Regular training sessions on abuse Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 16 awareness/prevention were provided for all staff to attend. Records inspected showed that appropriate pre-recruitment checks on new staff were undertaken prior to appointment (see standard 29). Anna Victoria Nursing Home DS0000015319.V330920.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, 26 Quality in this outcome area is good. Anna Victoria Nursing Home is clean and hygienic and aims to provide a safe, well maintained a homely environment but some health and safety risks prevent this always being achieved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the sluices, clinical room and the laundry. The home was in a good state of maintenance and decoration. There was a programme of regular maintenance in place. Communal rooms were Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 18 clean and well decorated and furnished to provide a homely environment for residents. Residents spoken with said the standard of cleaning was good and their rooms were cleaned daily. The gardens were attractive and well maintained and provided a pleasant outlook with good access for residents. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The door to the maintenance cupboard was left unlocked and the laundry door ajar when no staff were present. The home had a well-maintained passenger lift and ramps to enable access throughout the premises and to the gardens. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Designated storage areas for equipment were provided but these included areas in communal rooms. Call systems were provided throughout all individual and communal rooms. The premises were clean and hygienic throughout with no malodorous smells. Appropriate staff hand washing facilities (liquid soap and paper towels) were provided in all toilets, bathrooms en-suites and clinical areas. The home had several copies of the Infection Control Guidance for Care Homes published by the Department of Health but policies and procedures had not yet to been reviewed in line with the guidance. There were two mechanical sluices one on each floor of the home that had racking for storage of equipment. Clinical waste bins were observed overflowing with waste and therefore not locked as required. The laundry was small but well organised and equipped with two washing machines with sluice cycle and a drier that were well maintained. Laundry and sluice facilities were located away from areas where food was prepared or eaten. Anna Victoria Nursing Home DS0000015319.V330920.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, 30 Quality in this outcome area is good. The staffing levels (skill mix, number and competence) were appropriate to the needs of residents. Recruitment practices were thorough and promoted the protection of service users. Staff benefit from a supportive management team that develops skills and qualifications through an established training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were twenty-six residents at the home and staffing levels comprised: 1 registered nurse 6 care assistants in addition to the deputy manager (a registered nurse). Ancillary staff on duty included the administrator, the cook, two kitchen assistants, 1 housekeeper, 1 laundry assistant, 1 maintenance man and 2 domestic staff. Staffing numbers and skill mix met the levels agreed with the CSCI; from inspection of the staff duty rota and discussion with staff and residents, there was evidence that staffing levels were well maintained, and met the needs of residents. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 20 There were seven care staff with NVQ level 2 and four staff with NVQ level 3. This represents fifty per cent of the workforce as recommended in standard 28 of the National Minimum Standards for Care Homes for Older People. The files of four staff members were inspected: these contained evidence that all the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. Individual training records were inspected and showed that had received induction training. Records summarising training were also seen and showed that most staff were up-to-date with all mandatory training including health and safety, fire safety, basic first aid and moving and handling. However some ancillary staff had not received manual handling training. Training since the previous inspection had been provided on subjects relevant to a care home with nursing and included catheter care, wound care and dry mouth in the elderly. Anna Victoria Nursing Home DS0000015319.V330920.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, 33, 35, 38 Quality in this outcome area is good. The manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating a good understanding of their roles and responsibilities. The manager aimed to ensure good health and safety standards but some practices were evident that pose risks to service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 22 The registered manager, who is a registered nurse, had managed the home for several years and is supported by a deputy manager. The training records confirmed that both had current Nursing & Midwifery registration and had undertaken regular updated training. Relatives spoken with said they found the manager very approachable and kept them well informed. An annual plan had been developed since the previous key inspection. The home received monthly visits by a trustee of the organisation from which reports were made and available for inspection. However the reports needed development to record evidence that the premises and record of events and complaints had been inspected and to include the experiences of people living and working at the home. Some policies and procedures were under review. A service user questionaire had been distributed but there was no report available of the outcome. There was regular informal meetings with residents but no formal residents’ meeting had been held for some years. All residents had an advocate/representative to manage their finances on their behalf. Personal allowances were held for some residents. The personal monies of four residents were inspected and found to be correct with records and receipts held. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home was in the main safe, well managed and had the relevant health and safety practices in place. There was a health and safety policy statement and evidence that staff received training in health and safety. The majority of staff were up to date on fire safety and moving and handling training and regular updated sessions were planned. All accidents, injuries and incidents were wellrecorded and appropriate action taken. A maintenance cupboard containing tools was found unlocked and the external clinical waste bin was also unlocked. The premises were secure and there was evidence of risk assessments of the premises having been undertaken and appropriate action taken. Anna Victoria Nursing Home DS0000015319.V330920.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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X 3 X X x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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)(c) Schedule 1 Requirement The registered person must ensure that the statement of purpose is updated to reflect the end of life/palliative care provided at the home and a copy forwarded to the commission. The registered person must ensure that omissions of prescribed medication are monitored and the reason recorded on the MAR sheet. This is a repeat requirement The registered person must ensure that clinical waste bins are locked at all times. The registered person must ensure that the laundry and maintenance cupboards are kept locked when unsupervised. Timescale for action 30/06/07 2 OP9 13(2) 31/03/07 3 4 OP26 OP38 13(3) & 13(4) 13(4) 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 25 No. 1 2 3 Refer to Standard OP11 OP16 OP26 Good Practice Recommendations The registered person should review policy and procedures on end of life/palliative care. The registered person should review the complaints procedure in line with CSCI’s policy. The registered person should review policy and procedures on infection control. Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Anna Victoria Nursing Home DS0000015319.V330920.R01.S.doc Version 5.2 Page 27 - 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. 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