Inspection on 13/10/06 for Anville Court Nursing Home

This inspection was carried out on 13th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Anville Court Nursing Home 07/03/06

Anville Court Nursing Home 25/10/05

Anville Court Nursing Home 15/02/05

Anville Court Nursing Home 01/10/04

Anville Court Nursing Home 24/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Anville Court Nursing Home Anville Court Goldthorn Hill Penn Wolverhampton West Midlands WV2 4PZ Lead Inspector Keith Salmon Key Unannounced Inspection 13th October 2006 09:30 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 Anville Court Nursing Home DS0000017176.V307544.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. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anville Court Nursing Home Address Anville Court Goldthorn Hill Penn Wolverhampton West Midlands WV2 4PZ 01902 621771 01902 621498 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) www.bupa.com BUPA Care Homes (BNH) Limited Ms Elizabeth Ann Bevan Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (50), Terminally ill (5) of places Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories (except 5(only) beds Palliative Care) 7th March 2006 Date of last inspection Brief Description of the Service: Anville Court is a purpose built Care Home, comprising a two-storey building offering single accommodation with en-suite facilities to each room. The Home is registered to provide nursing and/or personal care for fifty older people, and may also provide services to persons with a physical disability or persons requiring palliative care up to maximum of 5. Standing in its own secluded gardens, it has car parking facilities to the front of the property. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection commenced at 09.30am, concluded at 3.00 pm (a total of 6.0 hours) and was conducted by Mr Keith Salmon and Mrs Debbie Sharman. Present for the Home was Ms Elizabeth Bevan, Registered Manager. The main objective of this Inspection was to review progress made by the Home in meeting ‘Requirements’ arising from the previous Inspection held on 7 March, 2006. This Report is a product of observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspectors also held 1:1 discussions with Mrs Bevan (Registered Manager), 10 Residents, 3 Visitors, and several members of Staff. At the time of this Inspection fees for care ranged from a minimum of £428 per week up-to a maximum of £700 per week. What the service does well: What has improved since the last inspection? Maintenance of Care Planning Documentation, specifically in relation to:Clarity and consistency of information within care planning documentation Identification of equipment used in the care of an individual and documented provision of that equipment Details of Risk Assessment including; pressure sore prevention/ management, moving and handling, and safe use of bedrails. Records indicating each Resident’s dietary intake are more detailed. Operating alongside this the Home has introduced a regime to help ensure the recommended five portions of fruit and vegetable per day is achieved for each Resident. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 6 In addition action has been taken in meeting a number of ‘Recommendations’ made at the previous Inspection relating to care planning documentation. 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. Anville Court Nursing Home DS0000017176.V307544.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 Anville Court Nursing Home DS0000017176.V307544.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. EVIDENCE: ‘Case Tracking’ involving the review of 10 Residents’ Care Plans/Files, (i.e. those relating to the four most recently admitted Residents, plus 6 selected at random), demonstrated all potential Residents have their care needs assessed by the Registered Manager prior to taking up residence. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan, utilised by the Home, is of a design, which is easy to read and comprehensive. The care provided by the Home is effective in meeting the Residents’ assessed care needs, and is delivered considerately and effectively. The storage, administration, and disposal of medicines are in accordance with accepted good practice. EVIDENCE: At the previous Inspection a number of ‘Requirements’ were cited under Standards covering Health and Personal Care. These being: OP7 1. (Target date 31/05/06) “The registered person shall ensure that care plans give clear, consistent information and are developed in consultation with relevant others at all times.” Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 10 2. (Target date 31/05/06) “Care plan records must specifically identify any type of equipment used to care for that person, with accompanying information to ensure it works effectively.” OP8 1. (Target date 01/05/06) “Individuals identified as at risk of pressure sore formation must be provided with appropriate pressure relieving equipment.” 2. (Target date 31/05/06) “Records of the food provided for residents must be in sufficient detail in order to demonstrate that the diet is satisfactory.” 3. (Target date 01/02/06) “Moving and handling risk assessments must be kept under review and be in sufficient detail so as to provide staff with the information they need to move the resident safely 4. (Target date 01/02/06) “To avoid confusion and standardise procedure the registered person must ensure that the risk assessments to support the safe use of bed rails are based on guidelines provided by HSE and the Medical Device Agency (MHRA) and be regularly reviewed.” As a component part of the ‘Case Tracking’ exercise, Care Plans/Files relating to 10 Residents (i.e. the 4 most recent admissions 6 others chosen at random) were reviewed and discussions held with the respective Residents. The Inspector specifically looked to see whether the Care Plans: Were easy to follow and understand Were current Provided involvement of SU/Relative/Advocate Made direct reference to equipment used in the care process Made reference to Risk assessment where indicated by the ‘care needs assessment’ process, e.g. pressure area risk assessment, action, management Provided evidence of regular audit by the Manager This process provided evidence that the Requirements relating to NMS Standards 7 and 8 have all been fully met. A Review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicines refrigerator temperatures), the maintenance of medicine Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 11 administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. The Inspector also reviewed the contents of the medicine trolleys, secondary/back-up storage and storage of medical gases. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities are provided, which are consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a carefully thought through menu offering a choice of attractive and nutritious meals. EVIDENCE: The Home now has a commendable programme of activities, which is comprehensive and varied. It is planned and organised, with enthusiasm and imagination, by a full time Activities Coordinator, who also works flexibly outside of the ‘normal’ 9am to 5 pm, e.g. to undertake 1:1 visits to the local pub, for shopping trips (utilising the ‘Ring and Ride’ System), or just simply talking with Residents. Without exception, the Residents commented on how much they enjoyed the way in which the Activities Coordinator very effectively integrates such 1:1 activities, particularly for those who specifically benefit from more direct personal attention. The Inspectors observed a 1:1 session, during which a physically disabled Resident was enabled to plant spring bulbs Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 13 into pots. Group activities include local trips out, with Relatives and/or Staff, including visits to the theatre, canal trips, and garden centres. Also traditional games such as cards, dominoes, bingo and skittles are played, as well as music and dancing, entertainment by visiting musicians and singers, quizzes, flower arranging sessions, make-up and nail care, celebratory card making, reminiscence activities (including use of local ‘yester-year’ photographs) and seasonal celebrations. Birthday celebrations for individual Residents are a regular feature. The Home is to be commended for their efforts in this aspect of care. Individual care records, and discussions with the Residents, demonstrated they are freely able to choose in which of the programmed ‘events’ they wish to participate. Discussion with the Manager and Cook, plus a review of menus, showed the Home’s meals are based on a traditional/seasonal daily menu with choices for Residents with personal preferences and dislikes. Information with regard to individual likes and dislikes is gained through the Cook undertaking a 1:1 interview with all new Residents within two days of admission – Residents confirmed this to be so. In addition, the Home has recently introduced a ‘light bites’ section to the menu, which offers a portion of fruit, or fruit juice, five times a day. This was seen to be operating and several of the Residents commented how much they enjoyed this extra variety to their daily diet. Also, to ensure Residents are given support when eating their meals the Home employs ‘hostess’ staff at breakfast time and lunchtime. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The interests of Residents are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. Staff are aware they have a role in protecting Residents from abuse. EVIDENCE: At the previous Inspection one ‘Requirement’ was cited under Standards covering Complaints and Protection, i.e. “The home’s policy regarding protection of vulnerable adults must be reviewed.” (Target date; 01/02/06, previous timescale of 31/1/05 not met) It was seen that satisfactory modifications have now been made to this Policy. Therefore, this ‘Requirement’ is met. Complaints Procedure details are included in the Service User Guide and are displayed prominently for the benefit of visitors. The Home has a policy and procedures in place intended to provide protection for vulnerable people. However, examination of Staff Training Files demonstrated only 50 of the Staff Group have undertaken Adult Protection Training. At the time of the Inspection the manger was unable to show the Inspector evidence supporting this training. However, prior to final publication of the Report satisfactory evidence was forwarded to the Inspector. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 15 Progress is inhibited by the non-inclusion of Adult Protection Training on the Training Matrix, but the Manager confirmed there are plans to transfer the information to a new format, and, henceforth, Adult Protection Training will be included. One Service User informed the Inspector that she had made two complaints concerning the approach of Staff, which had been investigated, one of which was upheld. In discussion with the Inspectors the Manager revealed she was unaware of the second issue and no records were available in respect of this, but did, however, undertake to actively pursue this matter as a complaint. Evidence of this was forwarded to the Inspector prior to final publication of this report. This showed that the second complaint had not in fact reached the Manager. Subsequent to the inspection visit the complaint was investigated and appropriate action taken. A letter of declaration to this effect, and a copy of a letter of apology to the Resident are on file. The Inspector is satisfied that the matter is closed. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 16 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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provides a generally safe, well-maintained environment offering bedrooms and communal areas, which are generally satisfactorily decorated. Furnishings are in good order and present a ‘domestic’ ambience. The gardens, which are a commendable feature of the Home, are easily accessible at all times of year. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, are available and found to be appropriately serviced and maintained. The cleanliness and general state of repair in the Home is good. EVIDENCE: A tour of the Home evidenced that the décor in bedrooms and communal areas is well maintained, with furnishings, carpets and curtains being of good quality and in a satisfactory state of repair. The gardens are spacious with wellmaintained lawns, well-stocked borders, mature trees, and bird feeding Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 17 stations offering additional interest for residents. The most recent formal sampling of views of service quality (questionnaires - surveyed Autumn 2005, results published February 2006) raised concerns by a small number of Residents regarding general levels of cleanliness, particularly the frequency of dusting. Observation by the Inspectors, during tours of the Home, showed the ‘housekeeping’ cleanliness, within the Home, to be in accordance with the view of the majority of Residents responding to the questionnaire, i.e. …”the Home is always clean”. In the same questionnaire one Resident complained of the loss of an article of clothing, whilst at the laundry, and another Resident complained about the quality of ironing. Inspection of the laundry evidenced well-organised systems to ensure Residents’ clothes are not lost, and ironing appeared to be of a high standard. Also, all Residents ‘case tracked’ confirmed to the Inspector that they had experienced no difficulties with the return of their personal clothing following laundering. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty and skill-mix were sufficient to meet the assessed care needs of current Residents. Whilst staff training and recruitment processes are generally adequate, Residents may be at risk as some members of Staff have commenced employment prior to the known outcome of their Criminal Record Bureau check. Most of the Residents appear satisfied with the approach and competency of Staff. EVIDENCE: Staff comments, made to one of the Inspectors, suggested that, at times, the staffing levels on duty leave staff who did come to work rather stretched if others call in ‘sick’. The Manager informed the Inspector that available staffing levels had been increased to help overcome this occasional problem. An examination of the current staffing rota, plus those from the immediately preceding weeks, demonstrated staffing numbers and skill-mix should be sufficient to enable a service provision, which comfortably meets the care needs of the Service Users. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 19 At the previous Inspection one ‘Requirement’ was cited under Standards covering Complaints and Protection i.e. “Staff records must be maintained as per schedule 4 and be available at all times for inspection. (Target date 01/02/06 - previous timescale of 31/3/05 not met) Review of the personal/employment records of the most recently appointed staff member was generally satisfactory, with the exception of two shortfalls. Firstly, it was found the required CRB check had not been received prior to commencement of employment at the Home. However, all other required documentation, including a check to ensure the person did not appear on local POVA listings, had been obtained and was satisfactory. The Manager acknowledged that such a situation (lack of satisfactory CRB check prior to commencing employment) should only occur in exceptional circumstances. It was noted the staff member involved has been, and still is, working under full supervision and on limited duties. The Manager also agreed that in future, in such circumstances, the situation must be subject to full, and documented, risk assessment to prevent any possibility of Residents being put at risk. The second shortfall was that there was no evidence in respect of a statement or doctor’s certificate regarding the applicant’s physical and mental health. This ‘Requirement’ remains unmet. Training opportunities are good with a planning system in place to support the provision of an on-going training programme, including an induction for new staff, to the appropriate level. The Staff Team has exceeded the national minimum target for numbers of Staff qualified to NVQ Level 2, with an attainment of currently over 50 . Discussion with Staff confirmed the training opportunities are available, including the provision of training to support most areas of specialist knowledge required by Staff to help to meet Service Users’ needs. Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The Home is well managed by the Registered Manager, Ms Elizabeth Bevan. Operationally, it is well organised with lines of accountability being very clearly defined and observed. The ambience is warm, friendly, and inclusive with the central purpose being ‘the best interests of Residents’. Improvements in the supervision of staff, and development of the ‘Quality Assurance’ questionnaires would help ensure even better quality of service provision. EVIDENCE: Analysis of the most recent service user satisfaction questionnaire results (Autumn 2005) showed, at that time, a good proportion of service users (43 ) judged staffing issues such as respectfulness and care as either excellent or Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 21 good. A sizeable portion (21 ) saw it as poor, whilst the remainder (36 ) felt service to be ‘neither good nor poor.’ Such a mixed response makes it difficult to arrive at a reliable and valid conclusion about Residents’ perceptions and feelings about the care they are receiving. Two criticisms of the Home’s quality surveying activities may be made. The first is the Questionnaire seems to be isolated, i.e. not part of an on-going series. This means there is reduced opportunity to make valid comparisons regarding changes in service quality from one time to another. Secondly, the time from sampling to reporting is too long (several months) to permit effective, and notable changes/ improvements to service provision. A ‘Requirement’ of this Inspection is the Registered Manager is to review the Home’s quality monitoring systems so that Residents’ views on service quality are sampled more frequently (as part of a series – perhaps 2 to 3 times per year) and subsequent analysis, reporting, and related action are completed speedily and are fully documented. To add further perspective, CSCI Comment Card entries from Service Users indicated a trend towards respondents stating ‘usually’ with some ‘always’ in response to questions about such items as staff availability, satisfaction with meals, cleanliness of the Home, and positive staff response to concerns they, or their Relatives, might have. Furthermore, on the day of the Inspection the majority of Residents, and Visitors, interviewed were very positive about there experiences in the Home, including such comments as; …“They can never do enough for us”, …“Nothing is to much trouble”, …“The staff are lovely”, “…. they take us out on lovely trips”, “…my Relative is getting superb care, in a very nice environment – and particularly has appreciated views of the garden from the bedroom. Furthermore, the Staff have been brilliant in looking after me when I visit.” Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 22 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 19. Requirement The Registered Manager must ensure new Staff do not commence work at the Home until all checks as specified under the relevant Regulation(s) and Standard have been satisfactorily completed. The Registered Manager must review the Home’s quality monitoring systems to ensure Resident’s views on service quality are sampled more frequently, and subsequent analysis, reporting, and related action are completed speedily and fully documented. Timescale for action 30/11/06 2. OP33 24. – (1) 31/12/06 Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 24 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 OP7 Good Practice Recommendations The registered person is advised to provide clarification to staff on the expected frequency of recording in the resident’s key worker diary (Recommendation made at October 2005 inspection-not assessed at this Inspection). Further develop individual training profiles for staff. (Not assessed at this Inspection). 2. OP30 Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Anville Court Nursing Home DS0000017176.V307544.R01.S.doc Version 5.2 Page 26 - 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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