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Inspection on 25/10/05 for Anville Court Nursing Home

Also see our care home review for Anville Court Nursing Home for more information

This inspection was carried out on 25th October 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents observed at the time of inspection appeared well cared for and staff were observed to be attentive in meeting residents needs. The home provides a range of suitable activities for residents and the actual environment is spacious and clean.

What has improved since the last inspection?

This is difficult to assess as only two requirements were made at the last inspection.

What the care home could do better:

Shortfalls identified at this inspection are regarding care documentation and the home`s adult protection policy.The registered person is required to keep care plans and risk assessments under review as it was identified during the inspection that documentation within resident`s care files had not been kept up to date. The adult protection policy had been identified as requiring review at the last inspection. It was identified at this inspection that this review had not taken place therefore the registered person must ensure that this policy is reviewed and amended by the 1st February 2006.

CARE HOMES FOR OLDER PEOPLE Anville Court Nursing Home Anville Court Goldthorn Hill Penn Wolverhampton West Midlands WV2 4PZ Lead Inspector Rosalind Dennis Unannounced Inspection 25th October 2005 11.00 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 Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 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.V264493.R01.S.doc Version 5.0 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) BUPA Care Homes 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.V264493.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No number division between categories (except 5(only) beds Palliative Care) 15th February 2005 Date of last inspection Brief Description of the Service: Anville Court is a privately owned care home that provides nursing, personal care and accommodation for fifty older people. It is also registered to provide services to people with a physical disability and for people requiring palliative care. Anville Court is a purpose built, two-storey building standing in its own secluded gardens. All bedrooms are single with en suite facilities. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted over a period of six hours on the 25th October 2005. The inspection involved talking with residents, visitors and staff, observing staff working with residents and examination of resident’s care files. The registered manager was not on duty at the time of inspection, the deputy manager and staff offered their fullest co-operation throughout the inspection. No formal complaints have been received by CSCI since the service was last inspected and there have been no referrals made under adult protection procedures. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls identified at this inspection are regarding care documentation and the home’s adult protection policy. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 6 The registered person is required to keep care plans and risk assessments under review as it was identified during the inspection that documentation within resident’s care files had not been kept up to date. The adult protection policy had been identified as requiring review at the last inspection. It was identified at this inspection that this review had not taken place therefore the registered person must ensure that this policy is reviewed and amended by the 1st February 2006. 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. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 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.V264493.R01.S.doc Version 5.0 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): 3 The home has a satisfactory admissions procedure that provides for an effective needs assessment for each resident. EVIDENCE: Observations of four care files demonstrates that comprehensive pre-admission assessments of prospective residents are undertaken in a variety of different settings such as other care homes, hospitals and the individuals own home. These assessments then form the basis for the care planning process. The home does not provide intermediate care; therefore standard 6 is not applicable to this home. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 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 and 10. Residents have care plans in place that identify their needs, however by not reviewing care plans and risk assessments in a timely way staff may not be provided with all the information they need to fully meet the residents needs. EVIDENCE: Five residents care files were examined in detail and deficits were identified in the care planning, review and risk assessment process. The majority of care plans contained in the files had not been reviewed on a consistent basis, care plans for one resident had not been reviewed for three months. Risk assessments had also not been reviewed regularly. One file contained a Waterlow skin assessment tool that had not been updated since January 2005 despite it being documented that the individual had a score of 16 which means they are “at risk” of developing pressure sores. Three moving and handling assessments had not been reviewed on a regular basis including one that had not been reviewed since March 2005 and did not contain information regarding the equipment needed to move the resident. Risk assessments for the use of bed rails were present on the files seen however these varied in their format and detail. One bed rail risk assessment Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 10 was comprehensive but was dated October 2004, another was handwritten but contained little information and two assessments were not dated or signed by staff. A wheelchair risk assessment was also observed not to contain a date or staff signature. Bed rails that were observed in use during the inspection appeared to be fitted correctly, discussion with the maintenance person confirmed his awareness of the homes bed rail policy and observation of records confirmed that checks on bed rails are included in the homes maintenance programme. Comprehensive wound care records were observed for a resident that had been admitted with pressure sores. The records, including photographs provide evidence of treatment, review and involvement of the tissue viability nurse specialist. The home maintains records of resident’s weights on a monthly basis, however the last recorded entry in one residents chart was January 2005. Discussion with staff indicated that this resident was immobile and unable to be weighed; therefore the home is advised to record the reason for not weighing individual residents A review of a key worker diary observed in a residents bedroom highlighted a lack of consistency regarding frequency of recording information with some entries happening on a weekly basis and other entries on a monthly basis. The last recorded entry was made in September 2005. Five residents that were spoken with during the inspection confirmed that the staff are helpful, respect their privacy and that the care is generally good. During the inspection staff appeared attentive and respectful of residents needs. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 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): 12 The home provides social and recreational activities that provide variation and interest for people living at the home. EVIDENCE: An activity notice board is available in the main reception area of the home, and this was observed to detail the activities for the forthcoming week such as, a Cheese and Wine evening, scrabble, outings to Wolverhampton and visits by a therapy dog. Entries made in care files document the residents attendance at these activities and a discussion with individual residents confirmed that suitable and sufficient activities are provided. Residents also confirmed that their choice to take part is always acknowledged. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 12 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): 18. The home provides training for staff on adult protection/abuse awareness, however the home’s adult protection policy requires amendment so that it does not provide staff with conflicting advice. EVIDENCE: An adult protection training session was provided in-house in August 2005 and records kept of staff that attended. A copy of the local “Multi-Agency Adult Protection policy and procedures” document was available in the managers office. A requirement was made at the previous inspection that the home’s policy regarding protection of vulnerable adults be reviewed so that it refers appropriately to adult protection procedures and does not provide conflicting information, such as the manager investigating incidents of abuse. A review of this policy evidenced that this document has not been amended and therefore remains as an outstanding requirement. Staff awareness of adult protection procedures was not assessed at this inspection. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 13 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): 26. The home provides residents with an attractive and clean place to live. EVIDENCE: A full tour of the home was not undertaken, however a random selection of individual and communal rooms that were observed were found to be clean and decorated to a satisfactory standard. Residents on both floors spoke of their satisfaction with their bed–rooms and with the level of cleanliness throughout the home. Observations made during the inspection confirmed that systems are in place to control the spread of infection and staff were observed utilising appropriate protective clothing when necessary. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 14 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. Staffing levels appear sufficient to meet residents care needs although a review of staffing allocation around mealtimes may further enhance the provision of care. EVIDENCE: The deputy manager confirmed that the staffing structure within the home is as follows: 4 care staff and 1 nurse on each floor during the day, 3 care staff and 1 Nurse on each floor in the evening and 3 care staff and 1 nurse at night. The manager is not included in these numbers. These were quoted as minimum levels and that the home will increase levels according to the needs and dependency of service users. Residents that the inspector spoke with confirmed that staffing levels appeared sufficient to meet their needs apart from around the time meals are served. Two residents described situations where they had to wait for staff to attend to them as staff were giving out meals and assisting with feeding. A discussion with staff also confirmed occasional difficulties with attending to care needs at mealtimes. It is recommended that the registered person reviews the allocation of staff duties at mealtimes and considers the appointment of a member of staff specifically to assist with the distribution of meals. One resident appeared particularly concerned regarding pregnant workers assisting with care. The deputy manager confirmed the home does currently have a high proportion of staff that are pregnant and that workplace risk assessments are routinely undertaken. An example of a risk assessment that Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 15 was observed demonstrates that the home takes into account health and safety issues for pregnant workers. Observation of staffing rotas confirmed that staffing levels have remained consistent through the use of bank staff. Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 16 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): The above standards were not assessed on this occasion. EVIDENCE: Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 17 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 2 8 2 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 14(2) 15(2) 13(5) Requirement Care plans and risk assessments must be reviewed and updated by staff at least on a monthly basis. 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. 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. The home’s policy regarding protection of vulnerable adults must be reviewed. (Previous timescale of 31/1/05 not met). Staff records must be maintained as per schedule 4 and be available at all times for inspection. (Compliance not assessed-timescale of 31/3/05) Timescale for action 01/02/06 2 OP8 01/02/06 3 OP8 14(2) 01/02/06 4 OP18 13(6) 01/02/06 5 OP29 17(2) Sch.4 (6)(f) 01/02/06 Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP8 OP8 OP7 OP27 Good Practice Recommendations If it is not appropriate to weigh a resident than it is recommended that the reason why the resident cannot be weighed is documented. The registered person is strongly recommended to ensure that staff sign and date all care plans and risk assessments. The registered person is advised to provide clarification to staff on the expected frequency of recording in the resident’s “key worker diary”. It is recommended that the registered person reviews the allocation of staff duties at mealtimes and considers the appointment of a member of staff specifically to assist with the distribution of meals. Develop individual training profiles for staff (Not assessed) 5 OP30 Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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 Anville Court Nursing Home DS0000017176.V264493.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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