Inspection on 20/09/05 for Anbridge Care Home

This inspection was carried out on 20th September 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.

Other inspections for this house

Anbridge Care Home 18/09/07

Anbridge Care Home 24/05/06

Anbridge Care Home 31/05/05

Anbridge Care Home 22/02/05

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

CARE HOMES FOR OLDER PEOPLE Anbridge Care Home 1 Herbert St Watersheddings Oldham Lancashire OL4 2QU Lead Inspector Carol Makin Unannounced Inspection 20th September 2005 10.00a 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 Anbridge Care Home DS0000062410.V249180.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. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Anbridge Care Home Address 1 Herbert St Watersheddings Oldham Lancashire OL4 2QU 0161 665 2232 0161 626 7836 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) Mrs Sally Anne West Mr Charles Paul Jones Mr Charles Paul Jones Care Home 20 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (14), of places Physical disability over 65 years of age (1) Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users to include: *up to 5 service users in the category of DE(E) (Dementia over 65 years of age) *up to 1 service user in the category of PD (Physical disability under 65 years of age) *up to 14 service users in the category of OP (old age not falling within any other category) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 31st May 2005 2. Date of last inspection Brief Description of the Service: Anbridge is a privately owned care home registered to accommodate 20 people. The home is situated in the Watersheddings area of Oldham and is within easy reach of shops, a park, and other community facilities. The building is a detached property with pleasant gardens to the front and rear, and car parking space to the side. Accommodation for service users is provided on the ground, first and second floors of the building. A passenger lift has been installed between these floors and ramped access has been provided externally. There are 16 single bedrooms, 11 of which have en-suite toilet facilities (four rooms also have an en-suite shower), and two double bedrooms, one of which has en-suite toilet facilities. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 20th September 2005. During the inspection the inspector spoke with some of the residents, the manager and a member of care staff, carried out a partial inspection of the premises, and examined records. Verbal feedback of the findings of the inspection was given to the manager, during, and at the end of the inspection. Action had been taken by the home regarding some of the requirements, which were made as a result of previous inspections. The timescale for action had not lapsed for one of the requirements, two had been fully addressed, some required further improvement to meet the National Minimum Standards and the Regulations, and there were others for which no action had been taken. What the service does well: What has improved since the last inspection? 50 of care staff had achieved NVQ 2 or higher. Staff have received training in relation to the Protection of Vulnerable Adults. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 6 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. Anbridge Care Home DS0000062410.V249180.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 Anbridge Care Home DS0000062410.V249180.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): 1,2 and 3 The information about the home, which is given to prospective residents, needed to be improved. A written statement of terms and conditions of residency was not provided for residents by the home. An assessment of needs was not carried out before admission to the home. EVIDENCE: The owner, said that there had been no progress regarding reviewing and amending the Statement of Purpose and Service User Guide since the last inspection. The Manager, reported that a new Terms and Conditions of Residency had been drawn up, but he had discovered that the document did not meet certain legal requirements, and professional legal assistance had subsequently been obtained to redraft it. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 9 The care files, which were inspected related to residents who had been admitted to Anbridge in recent months on a permanent basis, and had been in the home for a period of respite previously. A pre-assessment of needs was not completed on either occasion for one resident. One of the files contained an overview assessment and care plan, which had been provided by a care manager from the community prior to this admission, but it was vastly different from an assessment that was done in the home after admission. When asked about this during the inspection, the manager read the community care assessment, and said that he disagreed with it, and that in his opinion the resident’s needs were not as severe as those stated in the community care assessment. The manager was requested to put a report on the file to state that he disagreed with the community care assessment, and his reasons for doing so. He also needs to do his own pre-admission assessment of prospective residents needs. Standard 6 is not applicable to Anbridge as they do not offer intermediate care. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 More work was needed to ensure that all the health, personal, and social care needs of residents are fully met. Improvements are needed in the administration, recording and ordering of medication. Staff in the home respected residents’ rights to privacy and dignity. EVIDENCE: Care plans were in place on the files seen. The system in use was an individual book, ‘Assessment for Care Planning’. The format provided in the book was good, but improvement was needed in some areas of the content. For example, an aim on one file seen was to “ minimise risk of falls”, but there was no information about how staff should do this. There was also some confusing information about medical conditions, one example of which was a reference to a resident having “Crones Disease in her hands”. There was no evidence on the records to show that residents or their next of kin had been involved in drawing up the care plans, although there was a space on the care plan for their signature. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 11 Recording of residents weight was poor. The records consisted of communal lists of resident’s names on 2 separate sheets of paper. Most of the dates had been obliterated with correction fluid, making it impossible to know when residents had been weighed. There were gaps in recording the weight, and there was nothing on the records to show that when weight loss occurred, it had been investigated. Residents were not weighed on admission, and there was no record of the weight of one resident who was admitted early in June 2005, until 26/8/05. The system, which was used for care planning, contained a chart for recording the resident’s weight, but it was not in use on the files inspected. Since the last inspection, an advisor from ‘The Link’ centre in Oldham has provided a service for a resident who has suffered a sudden loss of sight. She has also been working with staff to enable them to gain insight into the needs of the resident, and assist them in meeting the needs. A sample of residents medication, and medication administration record sheets, were inspected and a number of concerns were identified, specifically: The home had run out of some medication for a resident. Some night time medication was not in of the blister pack, and there was no explanation of why it had been removed or of what had happened to it. Medication had been signed for, but remained in the blister pack. The issues noted in relation to standards 7-9 are referred to when reporting on standards 30,36, as they identify training/ supervisory issues for the manager. Residents felt that the staff in the home respected their rights to privacy and dignity. The need to respect and promote residents rights to privacy, dignity, and independence was also noted in their care plans. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15 Residents enjoyed the food provided, and they felt that they were able to exercise choice within the home. EVIDENCE: Overall residents were satisfied with the food at the home. Menus showed variety and choices of meals, with the main meal of the day being served at lunchtime. The inspector observed the evening being served, which was a choice of quiche, with or without baked beans, or a selection of sandwiches, followed by a choice of 2 desserts. Meals such as egg and chips were on the menu on alternate days for tea. The food was well presented, and staff were observed asking residents what they wanted to eat, and providing assistance appropriately where necessary. Residents said they enjoyed the food, and other comments included “they do me something else if I don’t like any of the meals”, “ we get enough to eat”, “we would never go hungry here”. Dining accommodation was provided in a separate dining room and an area of a small lounge. Residents who needed the extra support of an armchair, remained in the main lounge, and one resident chose to eat in her own room. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 13 Residents felt that they were able to make choices within the home. Meetings for residents were said to be useful, and one resident said, “you can have your say, and they keep their word about the things they promise to do”. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Information about the procedure for making complaints was not clear. Staff had received training to protect residents from abuse. EVIDENCE: The home’s complaints procedure did not meet the national minimum standards and the regulations. A record had been kept of a complaint, which was made to the owners by a resident in August 2005. The record contained details of the complaint, the action taken by the owners to address it, and their response to the resident. Since the last inspection training had been provided for staff in relation to the Protection of Vulnerable Adults. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 15 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): 23, 25 and 26 Residents’ bedrooms were satisfactory for meeting their needs. The home was clean, pleasant and hygienic. EVIDENCE: The parts of the accommodation, which were inspected on this occasion, were clean and free from offensive odours. Bedrooms rooms were furnished and decorated to a satisfactory standard, and residents were able to bring in furniture and other personal possessions of their choice to meet their needs, and make the rooms homely. Residents said that they were satisfied with their rooms. The manager said that whilst work to install radiator guards had not begun, arrangements were in hand for it to be completed within the timescale agreed at the last inspection. The requirement has been re-iterated in this report. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 16 As noted in the report of the inspection of the home in February 2005, a new industrial washing machine and a dryer were purchased in January 2005. During the inspection the owners spoke to the inspector about ideas they had for making improvements to the accommodation. Anbridge Care Home DS0000062410.V249180.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, 28, 29 and 30 The staffing levels within the home were sufficient to meet the needs of the residents. Recruitment practices were not sufficient to protect residents. Staff training in certain areas needs to be improved. EVIDENCE: Information obtained during the inspection indicated that staffing levels were generally satisfactory, but the hours when the Managers are on duty in the home must be included on the weekly staff duty rota. The owners reported that 5 of the 10 care staff (i.e.50 ), had achieved an NVQ level 2 qualification or higher, and the cook had begun NVQ 2 training in catering. The Manager said that new staff were employed on the agreement that they would enrol for NVQ training. Pay was used as an incentive for staff to undertake training, being linked to career development, with advancement to a higher rate of pay on successful completion of training. A sample of staff files were inspected, and a number of matters regarding recruitment procedures and recording were noted, and discussed with the owners. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 18 On one of the files discrepancies were noted regarding the date when employment had begun, although there was a clear indication that employment had begun before the references were received, and a CRB check from previous employment in another care home had been accepted. Another file showed that a member of staff who had previously worked at Anbridge had been re-employed, without new, up to date references being obtained. CRB checks are not ‘portable’, and a new CRB must therefore be obtained before employment commences, as are two up to date written references, and information about staff must be accurately recorded. Since the last inspection staff had received training in relation to the Protection of Vulnerable Adults. Records showed that the ‘Mulberry House’ 1day induction programme was in use in the home. During the course of the inspection, training needs were identified in relation to standards 7-9 and 38. Anbridge Care Home DS0000062410.V249180.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): 31,33,35,36,37 and 38 The registered manager is suitably qualified and experienced to run the home. Record keeping and procedures need to be improved to safeguard resident’s rights, and more opportunities were needed for visiting professionals and other interested parties to comment on the running of the home. Residents’ financial interests were safeguarded. Staff did not receive sufficient supervision and training in some areas. EVIDENCE: The joint owner and manager, Mr Jones is a qualified nurse, and he was the manager of a care home prior to purchasing Anbridge in December 2004. The owners, reported that no progress had been made regarding improving the system quality assurance and quality monitoring used in the home. Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 20 Records of money held in safekeeping for residents were selected at random for inspection, and were found to be in order. Training/supervisory issues noted in standards 7-9 have an impact on standard 36. Some of the records, which are required by statute, did not meet the standard, as noted previously in this report when reporting on standards 3,7,8,9,29,38. The manager said that whilst there was no specific policy/procedure for dealing with MRSA, infection control procedures within the home had improved considerably since the last inspection and he gave examples of this. He also said that the resident who this related to was no longer living at the home. It was, however recommended to the manager that information and a basic procedure regarding MRSA was provided for staff. An examination of the fire precautions records showed that tests and checks in relation to fire precautions had been carried out at the prescribed intervals with the exception of August 2005 when none had been done. There had been frequent fire drills and instruction sessions for day staff, but none for night staff. All staff need fire drill training at least once a year, to ensure that they are able to respond appropriately should the need arise. Maintenance contracts were in place for the emergency call system, the fire alarm, and emergency lighting, as was a service agreement for the passenger lift. Anbridge Care Home DS0000062410.V249180.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 2 1 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X 3 X 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation 4,5 Requirement The registered person must ensure that statement of purpose and service user guide are provided in accordance with the Regulations and the National Minimum Standards. The registered person must provide a statement of terms and conditions/contract for service users in accordance with the National Minimum Standards and Regulations. The registered person must ensure that a pre-admission assessment of service users needs has been completed to ascertain whether the care home is suitable for meeting the service users needs in respect of health and welfare. The registered person must ensure that care plans and risk assessments are provided in accordance with the National Minimum Standards and the Regulations. The registered person must ensure that care plans are drawn up with the resident and agreed, DS0000062410.V249180.R01.S.doc Timescale for action 01/01/06 2 OP2 5 01/01/05 3 OP3 14 07/10/05 4 OP37OP7 13,14,15 07/10/05 5 OP7 15 07/10/05 Anbridge Care Home Version 5.0 Page 23 6 OP8OP37 14 7 OP9OP37 13,17 8 OP16 22 9 OP25 13 10 OP27OP37 17(2) schedule 4 19, 17(2) 11 OP29OP37 12 OP33 24 signed and dated by the resident whenever capable, and/or their representative (if any). The registered person must ensure that residents weight are recorded on admission and subsequently, and monitored, and any concerns investigated. The registered person must ensure that medication is administered in accordance with the National Minimum Standards and the Regulations. The registered person must ensure that the complaints procedure is amended in accordance with the National Minimum Standards and the Regulations. The registered person must ensure that radiators and exposed pipe work within the home are enclosed. The registered person must ensure that details of when management are on duty in the home are included on staff rotas. The registered person must operate a thorough recruitment procedure, which ensures that service users are protected, and ensure that staff records are kept in accordance with this standard and the regulations. The registered person must ensure that quality assurance questionnaires are extended to include other stakeholders and the evaluation of the questionnaires is made available to prospective service users or their representatives, and the Commission for Social Care Inspection. The registered person must ensure that staff who are responsible for completing and DS0000062410.V249180.R01.S.doc 07/10/05 07/10/05 01/11/05 01/12/05 07/10/05 07/10/05 01/02/06 13 OP7OP8OP 13, 15, 9OP30OP36 17,18 OP37 07/10/05 Anbridge Care Home Version 5.0 Page 24 14 OP38 13,18 15 OP38 18 maintaining residents’ care plans and health records are appropriately trained and supervised. The registered person must ensure that tests and checks in relation to fire precautions are carried out at the prescribed intervals. The registered person must ensure that all staff receive training in fire drill training at least once in every 12 month period. 07/10/05 07/10/05 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 OP3 Good Practice Recommendations The registered person should ensure that a report is placed on the appropriate resident’s file, in the event of him disagreeing with the community care pre-admission assessment of needs. The registered person should ensure that information and a basic procedure regarding MRSA is provided for staff. 2 OP38 Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Anbridge Care Home DS0000062410.V249180.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!