Inspection on 06/02/06 for Avens Court Nursing Home

This inspection was carried out on 6th February 2006.

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 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

Avens Court Nursing Home 22/01/08

Avens Court Nursing Home 23/04/07

Avens Court Nursing Home 25/05/06

Avens Court Nursing Home 03/05/06

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

CARE HOMES FOR OLDER PEOPLE Avens Court Nursing Home Broomcroft Drive Pyrford Woking Surrey GU22 8NS Lead Inspector Cathy Clarke, Mary Williamson Unannounced Inspection 6th February 2006 10:40 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 Avens Court Nursing Home DS0000066356.V282329.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. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Avens Court Nursing Home Address Broomcroft Drive Pyrford Woking Surrey GU22 8NS 01932 346237 01932 336686 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) Surrey Rest Homes Ltd Care Home 60 Category(ies) of Dementia - over 65 years of age (45), Physical registration, with number disability over 65 years of age (10), Sensory of places Impairment over 65 years of age (5) Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users required to have a dementia disorder as their primary condition. Service users who have a sensory impairment must have these needs fully assessed and provision of specialist aids and equipment provided to ensure needs are met. The minimum number of care staff on duty excluding the manager must be: 3RN and 12HCA in the morning 07.45-13.45 3RN and 10HCA in the afternoon 13.45-19.45 1RN and 6HCA at night 19.45-07.45 RN: Registered Nurse HCA: Healthcare Assistant 05/01/2006 Date of last inspection Brief Description of the Service: Avens Court is a privately operated care home with nursing for older people with dementia. The home is situated in a quite residential area within a short distance of the shops and community amenities. The premises comprise of a large detached house with limited parking facilities at the front and an enclosed garden to the rear. Single and shared bedroom accommodation, some with en-suite toilet facilities is arranged on three floors, accessible by a passenger lift. Communal lounges and combined dining area are located on the ground floor. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced as a result of an anonymous complaint relating to: Care issues and practices relating to some service users in the home. The staffing levels, and recruitment practices. The management of infection and the supply of protective clothing. The inadequate heating arrangements in the home. The Inspection Mrs. Cathy Clarke and Mrs. Mary Williamson, both Regulation Inspectors undertook the inspection. Individual care plans relating to the named service users were examined. A pre-admission needs assessment was seen. The staff duty rota was seen. A tour of the premises was undertaken to visit specific service users rooms. The accident records were seen. Policies and procedures relating to the control of infection were seen. There was the opportunity to talk with some service users and staff. The inspectors would like to thank the provider and the home manager for their help during this inspection. What the service does well: The home provides care and support for service users with dementia. Avens Court Nursing Home DS0000066356.V282329.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. Avens Court Nursing Home DS0000066356.V282329.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 Avens Court Nursing Home DS0000066356.V282329.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): 3 Service users now have pre-admission needs assessments undertaken by the home manager. EVIDENCE: The manager stated that she undertakes pre admission needs assessments on prospective service users entering the home. The most recent assessment was seen on service user admitted on 16/01/2006. The manager stated that it had been the practice of the home that Mr Arjun Prasad, who is the health and safety representative and manual handling trainer, had been involved in the assessment of new service uses. A discussion took place with the home manager, Dr Prasad who is the provider and both inspectors, and concluded that service users pre admission needs assessments are only to be carried out by the manager or a qualified nurse with the training necessary to undertake such an assessment. A requirement has been made accordingly. Avens Court Nursing Home DS0000066356.V282329.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, and 8 Individual care plans identify, and outline how individual health care needs are met. EVIDENCE: The care plans of the service users identified in the content of the complaint were seen. Six care plans were examined. These were written on the basis of the initial assessment, information obtained from relatives and medical reports. These had been updated to reflect changing needs. Daily entries were made relating to care provided, records of GP visits and treatment prescribed to include antibiotic therapy. Detail entries were made on circumstances surrounding the service users who had died. For example when the GP visited and the time death was certified. One service user had sustained a fall on 26/01/2006. This was recorded in the service users care plan but not recorded in the homes accident records. A requirement has been made accordingly. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed at this inspection. EVIDENCE: Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 11 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): These standards were not assessed at this inspection. EVIDENCE: Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 12 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): 25, and 26. The home was warm, comfortable and well ventilated. There are procedures in place to protect the service user from infection. EVIDENCE: The complainant stated that the temperature in some of the rooms “are very much below normal”, and that “Disposable” heaters are being used. All the service users bedrooms and the communal areas of the home were warm and comfortable and all the service users sitting in the lounge and dining room were relaxed and did not appear cold. A discussion took place between the home manager and both inspectors regarding the heating in the home. The manager stated that on the weekend of 14th/15th January she had a telephone call at home from the nurse in charge stating that the home was cold as the heating was not working. The manager responded to the call by collecting four portable heaters on her journey to the home. When she arrived at the home she observed the temperature of the home was cold, and on further investigation that the heating had been Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 13 switched off. She turned the heating back on waited for the home to heat up and left the heaters in the office in case they were required. There are currently two service users in the home with MRSA infection. Both of these service users bedrooms were seen. Plastic aprons and disposable gloves are provided on wall-mounted racks outside these bedroom doors for staff to wear prior to attending to these individual service users needs. There are hand washing facilities, liquid soap and paper towels also supplied in these rooms to reduce the risk of infection. The infection control policy was seen and is written to protect service users and promote good practice. The manager was able to demonstrate to the inspectors the well-stocked storeroom, which contained ample supplies of gloves and aprons. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 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, 28, and 29. The number of staff on duty was adequate but some staff lacked the communication skills necessary to identify service users needs. The recruitment practice in the home is not safe. EVIDENCE: On the morning of the inspection there were nine care assistants, and three qualified RGN’s on duty, plus the home manager. The quantity of staff was sufficient to undertake specific task orientated care needs. The inspectors had the opportunity to talk with several staff throughout the visit. Mary Williamson spoke with two staff in the lounge at 2.15 pm. It was difficult to engage in conversation with these carers due to their limited language skills. They were unable to give an account of service users needs, and they were unaware of the control of infection policy. One staff member was asked if she had undertaken fire safety training but was unsure of the question. The manager and the provider are required to provide The Commission for Social Care Inspection with a detailed risk assessment and action plan outlining how service users will be protected at all times by the staff in the home to include responding to emergency situations and understanding care plans. The recruitment procedures in the home are poor. Five of the most recent staff employment files were sampled. All five did not have a Criminal Records Bureau (CRB) Disclosure in place. There were also gaps in employment history, which had not been explored. One staff nurse who has been working Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 15 at the home for over a year did not have a record of a CRB disclosure in place. The inspector requested to view a file on another qualified individual staff member, but this file was not in the home. An immediate requirement was made regarding recruitment practice and both home manager and provider reminded to provide supervision for all the staff in question until a satisfactory CRB disclosure is obtained. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 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): 31, 37, and 38. The home manager is working towards running the home in the best interests of the service users. She is working towards promoting health, welfare and safety of the service users. EVIDENCE: The home manager has been in post since November 2005. She is a qualified nurse and has had several years experience working as a CPN. She is currently working towards reducing the excessive hours some staff have been working, and all staff have been issued with new contracts of employment. She has also employed several new carers to implement this plan. This decision has been very unpopular among some staff who expressed their opinion to the inspectors during conversation. The manager stated that this had been discussed at staff meetings minutes of which were seen during the inspection. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 17 The manager also stated that one qualified member of staff was suspended from duty and a referral made to the Nursing and Midwifery Council (NMC) for gross misconduct. The manager shares an office with the administrator, which is situated close to the front door of the home. This is a very busy office and accommodates all the homes administration records. It also accommodates the telephones, computer, accounts, and staff employment files. The office is used to interview staff, relatives and was also the venue for the inspection, until the telephone engineer visited to maintain the telephones. The inspectors were concerned that sensitive and confidential information relating to staff personal details and the status of CRB applications are stored in the office and were the content of part of this complaint. The manager stated that the keys to the filling cabinet that contains all employment records and staff personal details had disappeared and then reappeared after a period of time. The inspectors, home manager and provider had a discussion on how to improve the current situation and it was recommended that the manager is allocated an office where personal files, supervision records and sensitive information can be stored safely and where interviews and private meetings can be conducted. The standard of record keeping varies. Records relating to the service users care for example care plans are well maintained. However employment records are well below the National Minimum standards. Health and safety policies and procedures are in place and some of these were sighted throughout the visit. The policy relating to infection control is written to protect the service users but it is difficult to establish how much of its content some staff understand. An action plan is required to be sent to The Commission for Social Care Inspection outlining how policies and procedures relating to health and safety are cascaded to staff in a format that they understand. Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 18 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 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 2 2 Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 19 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 28 Regulation 18(a) Requirement The registered person must ensure that at all times qualified, competent and experienced care staff are employed in the home in such numbers as are appropriate to for the health and welfare of the service users. The registered person shall make suitable arrangements to prevent infection, and the spread of infection in the home. The registered person must not employ staff in the home prior to obtaining all information listed in Schedule 2 The registered person must ensure that all accidents relating to service users are recorded correctly and retained in the care home The registered person must make suitable arrangements for all staff working in the care home to receive training in fire prevention, and must ensure that all staff understand this. Timescale for action 28/06/06 2 26 and 38 13(3) 28/02/06 3 29 and 37 19(1) 06/02/06 4 37 17(1)(a) (l) 28/02/06 5 38 23(4)(d) 28/02/06 Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 20 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 Avens Court Nursing Home DS0000066356.V282329.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Avens Court Nursing Home DS0000066356.V282329.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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