Inspection on 21/02/06 for Anna Victoria Nursing Home

This inspection was carried out on 21st February 2006.

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

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 16/02/07

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 21st February 2006 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 Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 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.V284840.R01.S.doc Version 5.1 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.V284840.R01.S.doc Version 5.1 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) 7th October 2005 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. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 22/02/06, lasting 4 hours. The inspection process included: discussions with the manager, the laundry assistant, two care staff, four service users and two relatives, a GP; a partial tour of the premises including observations on residents’ bedrooms, bathrooms, the laundry, the sluice, medication/clinical room and communal areas and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Seventeen standards were covered, and two requirements and one recommendation made. Action had been taken promptly to address previous requirements and recommendations. What the service does well: Anna Victoria provides a good standard of personal and nursing care. The premises provide a very homely environment and the gardens are very attractive. Registered nurses are skilled to provide palliative care through additional training undertaken. Care staff are well trained and there is good communication between the staff and GP’s. The home is approved to take student nurse placements, which enables staff to keep updated. There is good communication with residents/relatives. One relative commented on the improvement their loved one had made in walking since admission to the home. The nutritional needs of residents are well-monitored and appropriate action taken. The standard of catering is good with all meals including cakes baked on site using fresh ingredients. Individual preferences are catered for and efforts made to tempt those residents with poor appetites. Arrangements can be made for visitors to also have a meal at the home. Typical comments made were “The food is good”; “I have no complaints what so ever”; “The girls are very good, nothing is too much trouble”. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 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. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 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.V284840.R01.S.doc Version 5.1 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 the following standard(s): 1 Residents and their representatives had the information they needed prior to making a decision on admission to the home. EVIDENCE: The home had a statement of purpose and service user guide that was made available to residents and/or their representatives prior to admission. These documents detailed the homes aim and objectives/philosophy of care, services and facilities and terms and conditions of the home. Residents and their relatives spoken with confirmed they were aware of the statement of purpose and service user guide and had been provided with a copy. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 7, 8 & 9 Care planning is clear and consistent and provides staff with comprehensive information to ensure residents’ needs are appropriately met. The health care needs of service users are well met through close monitoring of changing needs and referral to the multi-disciplinary team where relevant. The systems for administration of medicines are good with clear and comprehensive procedures in place that are generally well adhered to. EVIDENCE: Three care files were inspected. Care documentation covered all key needs (physical and social) and provided good detail of the action required of staff to meet residents’ needs. Efforts had been made to ensure residents’ preferences based on their sexuality/gender were recorded. Agreement of the care plans was confirmed by signature of the resident/relative. Risk assessments for moving and handling, pressure areas, and nutritional risk assessments were recorded in all three files. Care plan for moving and handling of individual residents were also detailed for staff guidance. Daily records were detailed and demonstrated good monitoring of care needs with appropriate action taken. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 10 The home was supported by a local GP practice who undertook weekly visits and on request. Feedback from a visiting GP indicated that staff were well organised, referred appropriately and followed their instructions. Residents spoken with said that their personal care needs were met and that staff were very friendly and helpful. The records confirmed that residents received access to health care services as needed with attendance at outpatients as required. Regular and prompt referrals were made to health and social care staff as required. Good monitoring of health care needs was undertaken, including nutritional risk with regular weight monitoring and provision of specialist diets as indicated. Robust procedures were in place to ensure referrals were made as necessary to GP’s and a record was made of instructions to be followed that was audited daily. The home had policy/procedures for administration of medication. All medication was stored in the clinical/medication room and drug refrigerator temperature monitoring was undertaken daily. Registered nurses administered all medication. There were two trolleys, one used for AM drugs and one used for PM drugs. Medication administration records (MAR) were generally well recorded. Omissions of signature were monitored but did not detail the reason for the omission. All changes of prescribed medication had been signed as required by the GP. Reviews of medication were regularly undertaken by GP’s. Advice was given to ensure that the address was recorded on receipt and disposal of Controlled Drugs. A list of homely remedies was agreed with GP’s and reviewed annually. The home had a contract with a licensed contactor for disposal of medication. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 13, 14,15 Residents were encouraged to keep in contact with their relatives and friends through open access visiting. Residents were enabled to exercise choice and control over their lives. The home supplies sufficient quantity and quality of food, and provides a well balanced diet that meets individual needs and choices. Specialist diets are accommodated and efforts are made to tempt residents with poor appetites. EVIDENCE: The homes visiting policy was included in the statement of purpose and service users guide and encouraged family and friends to maintain contact with residents. Relatives and visitors were observed coming into the home at various times. Those spoken with said there were no restrictions on visiting times and they could see their visitors in private. One relative said that staff always made them welcome and they could also have a meal at the home. Residents spoken with said they were enabled a time in getting up and going to bed and could choose to eat in the dining room or their own room. Choices were also offered in what to eat or drink and how to spend their days or whether to take part in activities. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 12 The main meal on the day of the inspection comprised roast beef, Yorkshire pudding, roast and mashed potatoes and fresh vegetables with an alternative choice offered. The meal was well balance and looked appetising. Menus showed a good range of meals being provided and there was good monitoring of nutritional intake, with specialist diets accommodated. Residents and relatives said they found the food was good and there was always plenty to eat and drink. Residents were encouraged to eat in the dining room but could also choose to eat in their room. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 13 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 the following standard(s): Not inspected. EVIDENCE: Not inspected. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 22, 25, 26 Anna Victoria has the equipment necessary to maximise residents’ independence. The home was clean and hygienic with safe infection control practices evident. EVIDENCE: Since the previous inspection an additional hoist had been purchased. The home had sufficient pressure relieving cushions and mattresses to meet the needs of residents. Grab rails and ramps were fitted throughout the home to encourage independence and wheelchairs were available as needed. Small items of equipment for daily living such as special cutlery and drinking aids were provided as necessary. The heating, lighting, water supply and ventilation met the relevant environmental and health and safety requirements as evidenced from the home’s records. Rooms were centrally heated with controls in individual rooms and radiators were guarded as part of a risk assessment. The home was clean and hygienic throughout with no odorous smells. The infection control practices in place were observed to be safe. The home had Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 15 two sluice disinfectors, one on each floor of the premises that were well maintained. The laundry was equipped as required and well organised. Laundry and sluice facilities were located away from areas where food was prepared or eaten. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 The staffing levels (skill mix, number and competence) were appropriate to the needs of residents. Staff were well trained and competent to care for residents. EVIDENCE: There were twenty-eight residents at the home. 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. Turnover of staff was low and although some agency staff were used, residents were in the main cared for by staff who knew them. There were eleven registered nurses employed at the home. Of the twenty-one care staff also employed there were eight care staff with NVQ level 2 (38 ). Records summarising training were seen, and showed that most staff were upto-date with all mandatory training including health and safety, fire safety, basic first aid and moving and handling. Training had also been provided in abuse awareness, One registered nurse was undertaking a palliative care course bringing the total to five registered nurses with this qualification. Updated training was planned in wound care and infection control. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 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 quality assurance programme has commenced but further development is needed to establish an annual plan for the home. Residents financial interests are promoted and protected through robust systems that are well adhered to. EVIDENCE: The registered manager, who is a registered nurse, has managed the home for several years and is supported by a deputy manager. The manager and deputy manager were in the process of undertaking NVQ level 4 training that was due for completion by April 2006. The manager was in the process of developing a quality assurance policy. Residents’ questionnaires were distributed to residents annually but had not Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 18 yet been collated or used to inform the annual plan. Positive responses had been received on the home, care and staff. There were no formal meetings with residents or their visitors. The manager operated an open policy and was well known to residents and their relatives. Visits required under regulation 26 had been undertaken monthly and reports sent to the CSCI. All residents had a relative or advocate to manage their monies on their behalf. The manager ensured that residents were provided with sufficient funds. Small amounts of cash were held in the safe for residents and were appropriately managed with records of receipts maintained. The systems for the management of three residents’ monies were inspected and amounts were confirmed as accurate. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X x Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement The registered person must ensure that omissions of prescribed medication are monitored and the reason recorded on the MAR sheet. The registered person must ensure that records of medicines controlled under the Misuse of Drugs Act 1971, bear the name and address of the supplier/disposer. Timescale for action 10/04/06 2 OP9 13(2) 10/04/06 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. Refer to Standard OP33 Good Practice Recommendations The registered person should develop an annual plan for the home. Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Anna Victoria Nursing Home DS0000015319.V284840.R01.S.doc Version 5.1 Page 22 - 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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