Inspection on 11/11/05 for Anzac House

This inspection was carried out on 11th November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Anzac House 19/09/07

Anzac House 15/08/06

Anzac House 04/05/05

Anzac House 11/10/04

Anzac House 15/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Anzac House London Road Devizes Wiltshire SN10 2DY Lead Inspector Ms Sally Walker Unannounced Inspection 11th November 2005 09:30a 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 Anzac House DS0000028282.V261526.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. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Anzac House Address London Road Devizes Wiltshire SN10 2DY 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) 01380 722623 01380 730061 The Orders Of St John Care Trust Susann Linsley Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1) Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 30 service users with dementia at any one time One named service user in the category of mental disorder, excluding learning disability or dementia, aged over 65 years of age 4th May 2005 Date of last inspection Brief Description of the Service: Anzac House is situated on the outskirts of Devizes set in its own grounds. It provides care to older people with a diagnosis of dementia with one place for an older person with mental health needs. The home is not registered to provide nursing care. The home was built by the local authority in the 1970s and the accommodation is to 2 floors accessed by a lift and a staircase. The home is divided into separate units, namely Perth, Wellington, Canberra, Hobart and Melbourne. Each unit has its own sitting room, dining room and small kitchen. There is a central dining room and adjacent sitting room. All the bedrooms are single accommodation. The care staffing rota provided four care staff and a care leader during the waking day with three waking night staff. The home has 2 beds for respite care made available to people with dementia in the local community. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.30am and 5pm. Mrs Linsley was on a managers training course and Mrs Martine Glover, Administrator, assisted with access to records. The care plans, residents’ cash records, staff personnel and training records were inspected. Five residents were spoken with and 3 staff. The inspector gave feed back to Mrs Linsley on the telephone on her return from the course. Since the inspection Mrs Linsley has sent the re-decoration plan, the revised housekeeping task list and the list of refurbishments which are awaiting organisational approval, to the Commission. What the service does well: What has improved since the last inspection? What they could do better: Mrs Linsley and the staff are continually seeking ways to improve what is a specialist service to people with dementia. Now that much of the building has been redecorated and provided with new furniture other areas are looking tired and in need of improvement. Mrs Linsley has submitted her proposals for Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 6 further upgrade to the bathrooms, flooring and doors. She is awaiting confirmation from the organisation for the budget to carry out these much needed improvements. 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. Anzac House DS0000028282.V261526.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 Anzac House DS0000028282.V261526.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 Residents and their families can know that the home will gain as much information as possible to ensure that their needs can be met and the home is suitable for them. This is a specialist dementia service and confirmation of diagnosis is required. EVIDENCE: The care leader said that potential residents must have a written diagnosis before they are considered for assessment and this included emergency admissions. A care management assessment would also have to be provided at this time. The home would also visit the potential resident in order to carry out their own assessments as to whether their needs could be met. All admission were well planned with a check list for the staff admitting the resident to ensure that everything was in place for their arrival. This included prescribed medication confirmed with the GP. Anzac House DS0000028282.V261526.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 & 10 Residents care needs are well documented with regular reviews of care plans as needs changed. Residents have good access to specialist healthcare professionals and staff are prompt in referring any concerns. Staff value residents right to respect and dignity. Care staffing levels enable residents to have a quality of care and support. EVIDENCE: The staffing levels enable thorough review and revision of the care plans which is done every month, as care needs change and six monthly with the social worker and the family. The review encompasses all aspects of the care plan including the moving and handling assessment, weight, any restrictions, bathing and preferred routines for personal care giving, risk assessments and tissue viability. The records showed that when incidents occur an emergency review of the care plan is carried out with revision if necessary. The care plans were very detailed showing a good picture of the residents current care needs with guidance to staff on how to meet those identified needs. Statements in the care plans were about what residents preferred and highlighted what might make them anxious in terms of how the care is provided. There was guidance to staff on dealing with behaviours. Care plans were in place for those residents using the respite service. Mrs Linsley said that potential residents would not be considered unless there was a formal written diagnosis of Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 10 dementia and this was noted in the care plans. All care staff have received training in tissue viability from the specialist nurse and although there were no formal assessment documents being used, there were statements in immediate care plans that, based on the knowledge gained from the training in terms of dementia, weight and nutrition, some residents were at risk of developing pressure sores. The care leader said that once the risk had been identified, the details were sent to the district nurse for advice. Pressure relieving equipment was in place where indicated following the district nurse’s own assessment. The district nurse had trained staff in the monitoring of blood sugar levels for those residents who had diabetes. Juice and water was available in all the sitting areas for residents to help themselves. Residents had good access to healthcare professionals including the psychogeriatrician and community psychiatric nurse. It was clear from the records that any concerns over residents’ health and well being were referred to the relevant specialist. Records were kept of the results of these consultations. Anzac House DS0000028282.V261526.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 & 15 Staff ensure that they know residents social history to enable them to experience relevant activities. The activities role provides a good range of varied activities both in the home and the locality. Residents are encouraged to have a good diet with a varied traditional menu and regular nutritional monitoring. EVIDENCE: The home employs an activities co-ordinator and the different activities are displayed on a notice board each day. There was an activity for the morning and one for the afternoon. Care staff were also seen to be involved in the afternoon activities in each different area. Separate records were kept of residents involvement in activities. Families had been asked to give social histories to assist the activities provided. Mrs Glover said that they had found a need to develop specific activities for the men as many focussed on female residents, for example, beauty sessions or knitting. The home publishes a newsletter advertising all of the trips and special events and photographs of some of these were shown in the main entrance hall. The home does fundraising to pay for some of the activities, for example, taxis, refreshments and admission fees. The home had published the activities programme for the Christmas period. Some of the regular events included memory games and fragrances to stimulate reminiscence, trips to a butterfly centre, music, bingo, flower arranging, gardening, crafts, trips to the town for coffee or lunch and a trip to the local museum. Mrs Linsley and the staff reported on the many Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 12 benefits of having a member of staff to provide the activity programme; more residents were joining in and staff were more confident in providing other sessions. Some events would be held in the home for those residents who did not necessarily want to go out, for example, film afternoons and one event where a day at the beach was recreated with punch and judy and ice cream. A lay preacher had come to the home to take prayers with 2 residents of the catholic faith. The menu which was not dated, showed a good range of traditional foods with a choice for each meal. Residents could have a cooked breakfast 3 times a week. Mrs Glover said that the chef prepares the menus based on the current residents likes and dislikes and the menu was changed as preferences changed, for example, recent introduction of more spicy foods and finger foods. Some residents were able to have their meals in their rooms. Nutritional monitoring was in place and residents were regularly weighed. Those residents with whom the inspector could communicate said that they enjoyed the meals, they liked the range and that it was a different meal everyday. Some residents could not immediately remember what they had eaten for lunch and asked a member of staff to answer the question. The member of staff was very skilled at enabling the residents to remember the details of the meal. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 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): None of these standards were inspected at this inspection. EVIDENCE: Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 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): 19 & 26 Great efforts have been made to improve the physical environment for residents. Mrs Linsley is dependent on the organisation to confirm funding for the outstanding areas in need of upgrade. Mrs Linsley has addressed the cleaning issues noted at this inspection. Cleaning staff only work during the mornings and the allocation of hours to the home means it is a difficult task which is not always completed. EVIDENCE: Over the last few years great efforts have been made to improve the environment for residents. The main sitting room and dining room area had been transformed with redecoration, new carpets and new furniture. Bedrooms were redecorated as they became vacant and were personalised and comfortable. All of the corridors including the small sitting rooms, dining rooms and kitchenettes had been redecorated to a good standard by the handyman. There were some areas which had not benefited from the redecoration programme and now appeared tired and neglected in contrast. These areas entailed a major capital outlay which had to be agreed by the organisation. Mrs Linsley said that new carpeting to all the corridors had been agreed and was to be laid towards the end of the month and one of the Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 15 bathrooms was to be refurbished. She said that all other items, for example, refurbishment of the remaining bathrooms, carpeting of the back stairs and replacement door to some of the toilets and bathrooms would have to go to the organisation for approval. The inspector advised that the action plan for the conclusion of the full upgrade to the building must be sent to the Commission. Since the inspection Mrs Linsley has supplied her maintenance plan which has been submitted to the organisation and includes: replacement of the toilet and bathroom doors to Melbourne area, replace the carpets to the corridors in Melbourne and Canberra and the foyer. She has said that further requests are to be submitted to the organisation once the budget had been agreed. Mrs Glover reported that they were experiencing problems with the heating which were being addressed by the contractor. She said there was hot water and it was noted that the problem was resolved by the early afternoon. There did not appear to be any detriment to the residents during this time. Some of the bathrooms were in need of a deep clean; for the removal of build up of lime scale in the baths and under the bath hoists, build up of dust and talc on the base of the mobile hoist and in the fabric chairs, and for the removal of brown smears on the tiles near the toilets. This was pointed out to Mrs Glover who immediately addressed the matter. The inspector had spoken to one of the 2 housekeepers earlier and they reported that they only worked mornings and spent some of their time in the kitchen helping with washing up. As all of the staff had undertaken training in infection control it was not a matter of education but of resources. Clearly these 2 staff have an enormous task in ensuring the cleanliness of the whole building during the time allocated and it is not surprising that some areas are missed. It must be said that the home did not have any unpleasant odours. There were also a quantity of unused catheter bags being stored in the hairdressing room and a set of false teeth left on the side in a bag. As a matter of good practice it was noted that all of the wheelchairs were clean and had footrests attached for the safety of residents. Since the inspection Mrs Linsley had confirmed that she had arranged to meet with the housekeeping staff to discuss her revised housekeeping task list. Mrs Linsley has also confirmed that she had met with individual staff and improvements have been made. The home had a contract for the disposal of clinical waste. The care leader said that all staff had recently been trained in fire prevention from a specialist trainer. Residents bedrooms were identified by either their name or a picture. Mrs Linsley said that she had considered changes to the environment to enable residents to access different areas as recommended by research into dementia care. She said that no colour changes had been made as all of the residents were able to find their rooms, the bathrooms and toilets and other communal areas. This was confirmed by observation and by asking residents. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 16 There was a well organised laundry system with a member of staff working weekday mornings. Laundry was separated according to temperature and a safe system was in place for dealing with soiled or contaminated laundry. Residents’ clothing looked well cared for. The laundry person explained that they would collect towels and laundry from residents and deliver their clean clothing. She said that new matching bedding and towels had been ordered. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, 29 & 30 Residents have benefited from improved care staffing levels. Staff are well trained to be knowledgeable in providing dementia care. Robust recruitment procedures are in place for the protection of residents. EVIDENCE: The care staffing rota for that day showed that there were 4 staff and 1 care leader on duty during the waking day throughout the week. At night there are 3 waking night staff. There were also the chef and 2 housekeepers, the administrator, the activity person, the laundress and the day service leader. The cleaning staff and laundry person work mainly during the morning so care staff are expected to carry out their duties at other times. There is no laundry person at the weekends but there was a kitchen assistant during the evenings to do the washing up and other kitchen duties. Although it is recognised that the care hours have been increased by 52 hours since April, and this has had a significant impact on improving the care provided, the home should consider the support staff allocation given that care staff are expected to carry out cleaning and process laundry when these staff are not on duty [see Standard 26 on cleanliness]. It was noted that the care leaders were not keyworkers to residents and as such could concentrate on leading the shift, dealing with day to day management and administrative duties. One care leader said that they would do some caring when required. They went on to say that each care leader had delegated management responsibilities, for example, the medication. A policy was in place for risk assessment of staff working whilst pregnant. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 18 All staff were seen to engage with residents including those not necessarily in a caring role. Those residents with whom the inspector could communicate made very positive comments about the staff. One resident said staff listen to them. Another resident said they felt well supported by a particular member of staff who they identified. Recruitment procedures were satisfactory with all prospective staff having to declare their qualifications, experience and history in a written application. The home kept records of interview, two referees, copies of training certificates and medical history in line with all the documents and information required in Schedule 2. No staff commenced duties without a Criminal Records Bureau certificate being applied for and confirmation of a POVA check. Mrs Linsley had produced a training matrix to show training need throughout the year and the status of each member of staff with regard to core relevant training. Three staff held NVQ Level 3 and 3 staff were undertaking the award, 10 staff held NVQ Level 2 and 9 were undertaking the award. All staff had undertaken training in dementia, food hygiene, health and safety, risk assessment, moving and handling and abuse. The majority of staff had trained in first aid. Dementia care training was mandatory and a programme was planned for the coming weeks where all staff were attending and expected to complete a workbook. All staff had regular supervision with a plan in place for sessions throughout the year. Staff said that regular staff meetings were held throughout the year. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 19 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 Mrs Linsley runs the home in the best interests of the residents. The home benefits from her recently attaining the Registered Managers Award. Systems are in place to ensure safe handling of residents monies. EVIDENCE: Mrs Glover explained the system for holding monies on residents behalf. Small amounts can be held in the safe with records being kept of all transactions. Only senior staff have access to the safe. The organisation had recently audited the home’s finances. The inspector advised that the policy on receiving cash should be reviewed to include two signatories on receipt of monies in line with the policy for withdrawing monies. Mrs Glover said that no valuables or personal savings were held on residents behalf. Families or relatives were encouraged to retain these items if residents did not have capacity. Mrs Glover kept records of the collection of 3 residents pensions. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 20 Mrs Linsley had attained the Registered Managers Award. Since the inspection she has responded to the feedback with provision of a maintenance plan for the year 2005/05 and a revised cleaning schedule. Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP26 Regulation 23(2)(d) Requirement Timescale for action 11/11/05 2 OP19 23(2)(b)& (d) The person registered must provide sufficient resources to ensure that all areas of the home can be cleaned to a good standard at all times. The person registered must 01/04/06 confirm with the Commission when the budget has been agreed for the final refurbishments of the building together with timescales for completion. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Anzac House DS0000028282.V261526.R01.S.doc Version 5.0 Page 24 - 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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