Inspection on 18/10/05 for Anchor House

This inspection was carried out on 18th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Anchor House 08/09/09

Anchor House 11/09/07

Anchor House 26/09/06

Anchor House 14/06/05

Anchor House 30/11/04

Anchor House 05/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Anchor House Anchor House Anlaby Road Hull East Yorkshire HU3 2PB Lead Inspector Angela Sizer Unannounced Inspection 18th October 2005 10:30 Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 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 Anchor House DS0000000878.V258448.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 Adults 18-65. 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. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Anchor House Address Anchor House Anlaby Road Hull East Yorkshire HU3 2PB 01482 326572 01482 580671 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) English Church Housing Group Limited Ms Anita Lovelock Care Home 40 Category(ies) of Past or present alcohol dependence (3), Mental registration, with number disorder, excluding learning disability or of places dementia (40) Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of three residents with past or present alcohol dependency Date of last inspection 14th June 2005 Brief Description of the Service: Anchor House is a care home providing personal care and accommodation for up to 40 younger adults and older persons who have enduring mental health problems and past or present alcohol dependence. The English Churches Housing Group owns the home. It is situated on Anlaby Road a short distance from the centre of Hull and its extensive facilities. The home was opened in January 1989 and consists of 40 single bedrooms, 34 of which have an en-suite facility. The home is a three-storey building with a connecting passenger lift. There are four toilets, one shower and two bathrooms that are for general use. There is a secured front entrance that is monitored by CCTV, two lounges one being a designated smoking area, a separate dining room. Outside to the front of the building is a large car park and to the rear an enclosed courtyard, which has seating, and a patio which service users access on a regular basis. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 8.30 hours and preparation work took a further 3 hours. A tour of the home was undertaken and during this time lunch was observed. Around 14 residents and one staff member were spoken to throughout the course of the day to find out what it was like for people who live here. The registered manager was present throughout the inspection and was told how the inspection had gone at the end of the day. Residents and staff files were looked at and also other paperwork relating to the running of the home. The outstanding requirements were discussed and the manager gave an update, several continue to be unmet. What the service does well: What has improved since the last inspection? The home offers support to residents who have a variety of needs and on the whole are met. Staff receive training in many areas and this helps them to Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 6 look after the residents. Staff support residents to be as independent as possible. The homes and English Churches Housing recruitment and selection procedure is robust ensuring that the residents are protected from abuse. The risk assessment documentation is very good, clearly stating the risk and how this is reduced or managed, this clearly shows that residents are helped to live their life as they wish and be kept as safe as possible. 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. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 5 The homes admission procedure is not always adequate, it was seen to be contradictory to their policies and procedures. Therefore it does not provide individuals with the assurance that their needs can be met prior to the coming into the home. EVIDENCE: The issue of the current registration was again discussed and the registered manager has obtained a variation application form and is planning to apply to register for up to 20 residents in the category of OP (old age), the home currently has 17 service users over the age of 65 and a further two over 60. The statement of purpose does not include information about how those residents’ needs would be met. Consideration must be given to varying the registration and updating the statement of purpose. A condition of registration will need to state that the home cannot accommodate any person with physical needs due to the environment. The home does undertake an assessment in addition to the Local Authorities community care assessment. A care plan is formulated from the information gathered and on the whole these are very good with clear direction to the care staff. There are risk assessments in place that give clear direction to staff. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 9 One resident who was admitted with alcohol related problems does not have a mental health need. From discussion with the resident, family, manager and social services it was clear that the primary need was alcohol related, but there was no evidence to confirm that a alcohol rehabilitation programme was in place nor had there been a medical assessment undertaken to identify what specialist support this person may require. Staff had not received any alcohol misuse training. The home has a no alcohol policy and this must be considered when admitting a person who has alcohol related problems. From speaking to individuals it was confirmed that usually new residents have the opportunity to visit the home. The home does not provide written confirmation to the resident that they will be offered a place or the reasons why if a place is declined. The home offers each resident a contract this covers all areas in standard 5. From speaking to residents it was clear that they understood what the contract was for, there was written evidence on residents files confirming they had signed the document. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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 Not all residents are able to make choices and decisions. Not all residents are supported to take risks as part of an independent lifestyle. EVIDENCE: During the course of the day many of the residents were spoken to confirming that they are able to make decisions and choices about their lives. Some stated “we are involved in residents meetings and staff listen to what we have to say”. Residents spoke about two holidays they have been on this year “it was great and I met some new people who were very nice” and “I enjoyed the camping best”. One service user is the chairperson for the residents group, describing how much this has enabled her to do. “I feel more confident and assertive since I have been doing this. I have recently been on a conference dealing with chairing meetings”. Residents are also involved in the recruitment process for new staff, one person stated that “we talk to the person first to find out if we like them and whether or not we think they would be good to work here”. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 11 The home has a thorough risk assessment procedure, documentation is clear and informative giving direction to staff. Confidentiality is maintained within the home, residents said that they felt comfortable in talking to their key worker about personal issues and understood when this may have to be breached. Documentation is kept in a secure cabinet and locked office. Residents who endure alcohol dependency do not have their needs fully met, as the home operates a ‘no alcohol’ policy and does not allow for any rehabilitation programme that may involve the reduction of alcohol intake. None of the staff have received training with regard to alcohol issues. One resident who spoke to the inspector throughout the day stated that he did not feel that he was able to make choices for himself, but that relative, social workers and staff at the home made them for him. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14 & 17 Residents are supported to fulfil their social needs. Social activities are well organised and held on a regular basis. EVIDENCE: From speaking to approximately 14 residents it was clear that they feel supported in living as independently as possible. Many of them spoke about the home and staff fondly stating that “we can come and go as we like” and “I can go out staff when they have time”. The home offers various in-house entertainment ranging from pampering nights to theme nights enabling the residents to participate in varying social activities. Residents stated that “most of the staff are very supportive, they listen and help us”. This year the home has taken 8 residents to Bridlington for 3 days in a bed and breakfast hotel and also a camping trip to Cleethorpes, these were funding by a former resident who passed away. One resident described how she was the chairperson for the residents group and how this has given her more confidence and assertive skills. She has also attended conferences in relation to chairing meetings. She stated that “I really enjoyed my trip and gained a lot from it”. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 13 Some of the residents maintain contact with their family and friends, others have little contact due to their illness. Relationships are supported and many of the residents said they had a partner or were in a relationship. The home offers training to staff with regard to sexuality and relationships. Several service users described rejection and stigmatisation by members of the wider community. The menu is rotated on a monthly cycle and consists of four meals during the day all of which offer the service user choice. Lunch was observed and sampled it consisted of homemade meatballs, peas, swede and boiled potatoes or carbonara followed by semolina, yoghurt or fruit. Tea consisted of soup, sausage and onion pie with salad or kippers and tomatoes. A cooked breakfast is offered three days a week. The kitchen staff have received training in relation to food hygiene and some of them have attained an NVQ qualification. The home has been awarded the Heartbeat award until October 2006. Residents confirmed that they enjoyed the food and were happy with the choices available. Any suggestions are written down and reviewed regularly as part of the quality assurance process. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Not all of the residents’ personal and healthcare needs are met. EVIDENCE: On the whole the general personal care needs of residents are met, from speaking to several individuals they stated that any personal care support is offered in a sensitive manner and in the way that they prefer. One resident said “my key worker is very good and makes me feel better when I am down”. A discussion occurred with the registered manager with regard to the 17 residents who are over 65 years of age and may require technical aids and adaptations, these individuals will need to be assessed by appropriate professionals. The manager is aware of the Older Peoples National Minimum Standards and is going to obtain a copy to familiarise herself with them. The home has good links with the local community psychiatric teams and GP’s in the area. A form is now in use that details all medical appointments including GP, Community Psychiatric Nurse, Dentists and Opticians. Since the last inspection all staff have undertaken medication training. The training is accredited by Alliance Pharmacy and covers the safe handling of Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 15 medication. It is a workbook-based course; the Pharmacist assesses each module. Mostly senior staff administer, but occasionally care staff do undertake this too. The registered manager has updated the local medication policy to include the refusal of medication. From direct observation it was identified that the recording continues to be of a poor standard, also when PRN medication was crosschecked with the MAR the amount remaining was incorrect. Although there is a policy regarding refusal of medication, it does fully cover this and it was found that when residents went out for the day medication was been given upon their return, this was been carried out without consultation with the Pharmacist or GP. A recent visit from the Pharmacist identified that the medication refrigerator needed replacing and that the home must store and record controlled drugs in accordance with the Royal Pharmaceutical Guidelines, stating a metal cabinet secured to the wall inside the medication cabinet. The home has obtained a metal cash tin, but this is not secured to the wall and can be removed. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not looked at during this inspection EVIDENCE: Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 The environment is clean and tidy and suitable for it’s stated purpose. Some of the service users individual accommodation does not fully meet their needs. Toilets and bathrooms provide sufficient privacy. EVIDENCE: The registered manager stated that the long-term plan for the home has noT been decided at this current time. During a tour of the premises the home was found to be clean, tidy with no offensive odour. The home has a domestic team who work very hard in maintaining a clean environment. Due to the building being extensive a selection of bedrooms were chosen to look at and the majority of these were of good decorative order and furnished to a good standard. One resident took pride in showing his bedroom and the fact that he had chosen the colour scheme. Several of the rooms had a piece of wood secured to the wall for a headboard; from speaking to several residents it was evident that these are not comfortable. The premises are located on a busy road and have a variety of local amenities nearby. Local transport is available outside of the gate to home and the city centre is a short distance away. Rooms 203 and 217 – the carpets had numerous cigarette burns and were badly stained. In several of the rooms the towels were dirty and from speaking to the registered manager it was stated that these are changed with the bedding on a weekly basis. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 18 Some residents have purchased their own furniture, this has been by choice and is recorded on their individual files. All rooms are lockable and a key is issued to all residents. The home has 40 single rooms, 34 of which are en-suite. The communal baths have regulator valves fitted to ensure that the hot water is dispersed at approximately 43ºC and this is monitored on a weekly basis, but the wash hand basins were found to be distributing at above 60ºC. The laundry floor remains in poor repair and could pose a risk of falling or a trip hazard. A recent Environmental Health Department visit highlighted the need to replace the kitchen floor, this is due to take place week beginning 31.10.05. The home has made alternative arrangements for meal times and food is to be purchased in already cooked, this has been discussed with the residents and they are fully aware of the reasons why. There is a rehabilitation kitchen on the first floor and this is used when a resident requires support as part of their care package. The kitchen is not inspected by Environmental Health, the registered manager is going to check whether it is required to be. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 36 Residents are cared for by staff who have been properly recruited and are generally well trained for the main registration category. However, the staff numbers and abilities of staff to care for the minor registration category of Alcohol Dependency compromise the quality of care for some. EVIDENCE: The situation regarding staffing levels is the same as stated in the previous inspection report. Minimum staff are on duty to offer basic care, both residents and staff confirm that more time is needed on an individual basis. A calculation of the actual hours required was undertaken and the Department of Health guidance states that 785.35 care hours are needed and currently 497.50 are provided. There are currently two vacancies totalling 75 care hours. 4 care staff are on duty from 7.30 am to 3.30 pm, 3 are on duty from 2 pm to 10 pm and there are 2 waking night staff. The manager’s hours are in addition to these, but this leaves a considerable gap in what the current guidance actually stipulates. Given the aging population and increased dependencies this places further strain on staff to care for residents. In the light of this action the time scale to achieve the statutory requirement is extended. If this timescale is not adhered to the CSCI may consider enforcement action. The organisation has a robust recruitment and selection procedure ensuring the health and safety of the service users. Minor parts of the standard were not met, the staff files looked at did not contain a photograph or form of Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 20 identification. CRB and POVA 1st checks are undertaken prior to a person commencing employment. A health declaration is signed confirming that the individual is mentally and physically fit. It was explained that this information was held at the group headquarters. The photograph, identification and references must be kept within the home. Examination of records and interview with staff indicated a high level of specific training and a level of qualification above the 50 recommended minimum. During the course of the inspection staff were observed interacting with residents and on the whole this was conducted in a supportive, caring and professional manner. One staff member was directly observed speaking to a resident in a curt and abrupt manner, the resident then stated that this was a regular occurrence. This issue was discussed with the registered manager and she confirmed that there had been previous complaints/issues and that this had been discussed during supervision. Supervision is offered every six weeks to all staff, this is recorded and kept within the staffs file. Care staff confirmed that they received support both formally and informally on a daily basis. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 The day-to-day management of the home is good, the home is well organised and policies and procedures ensure the health and safety of the service users. Service users who have alcohol dependency do not receive support from trained staff. EVIDENCE: The registered manager has obtained an NVQ level 4 in both Care and Management, she has many years experience of working with people who have mental health problems and shows a good understanding of residents needs. From discussion it was clear that neither the manager nor the care staff have undertaken any alcohol dependency training and as the home is registered for this area. The organisation will need to review the registration in relation to the 3 beds identified as Alcohol Dependency past or present and either offer specific training to the manager and staff, up date the statement of purpose, contract and service user guide in order to accommodate these specific needs or remove this part from the registration and solely offer support to those with mental health problems. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 22 The home is warm and friendly and residents stated that the manager is “lovely” and “a real gem”, it was clear that she is well respected by both residents and staff members alike. The manager confirmed that she operates an open door policy and is available wherever possible, during the inspection several residents came in and out of the manager’s office for various advice and information. She responded in a respectful, caring and empathic way. There is a clear sense of leadership and direction, the procedures are open and transparent. The home’s quality assurance system is well developed, but remains unmet as stated in the last report. Residents, family and other professionals are consulted, but currently the home does not produce an annual report. The home has a range of policies and procedures covering all areas detailed in Appendix 2, these are regularly updated and reviewed. One area that caused some confusion was the alcohol policy, which states that the home has a ‘no alcohol’ policy. The home also offers support for up to 3 people who have alcohol dependency, this could have a detrimental affect upon their well-being and health and requires further consideration. Since the previous inspection the workplace risk assessments have been updated. The home has the relevant maintenance certificates in place. Induction is offered to all staff, there is a local and corporate training programme covering the specification of the Skills for Care. Foundation training is offered and the home accesses some of the Social Service Department training, all of the mandatory training areas are up to date including fire safety, health & safety and first aid training. Some staff also undertake other specialist training, this has included epilepsy, challenging behaviour, diabetes. The Environmental Health Department made a requirement for the kitchen floor to be replaced, this is planned for week beginning 31.10.05. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 X 2 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X 2 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 1 1 X 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Anchor House Score 2 3 1 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X 3 X DS0000000878.V258448.R01.S.doc Version 5.0 Page 24 Yes 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 YA1 Regulation CSA 2000 Requirement The registered person must apply for a variation of registration for up to 20 MD(E) older persons living in the home (Previous timescale not met – 01/09/05) The home’s statement of purpose must include details about alcohol dependency, staff training and a clear admission procedure. The home must not offer a place to someone whose needs it cannot meet. The registered person must ensure that residents’ who have alcohol dependency are enabled to make choices about their lifestyle. Medication must be given out as prescribed or directed by GP or Pharmacist. Controlled drugs should be stored as directed by the Pharmacist, the controlled drug cupboard should be secured to the wall inside the medication cabinet. The medication procedures should contain details of all the DS0000000878.V258448.R01.S.doc Timescale for action 18/12/05 2 YA1 4,17 Schedule 1 4,14 12 18/12/05 3 4 YA3 YA7 18/12/05 18/12/05 5 6 YA20 YA20 13,17 13,17 18/12/05 18/12/05 7 YA20 13,17 18/12/05 Anchor House Version 5.0 Page 25 8 YA24 23 9 YA24 13,16,23 10 11 YA26 YA27 16,23 16,17,23 12 YA32 18 13 YA33 18(1) 14 YA34 17,18,19 15 YA37 17,18 16 YA39 17,24 areas mentioned in the Royal Pharmaceutical Society guidance for care homes. In particular the refusal or omission of prescribed medication. The registered person must make safe the floor in the service users laundry.(previous timescale not met – 01/03/05) Clean towels must be provided on a regular basis ensuring infection control and the health and safety of service users. The registered person to ensure that all bedrooms have a comfortable headboard. The hot water to be monitored and risk assessments to be undertaken with regard to all communal wash hand basins. Staff must respect service users in accordance with the General Social Care Council code of conduct. The registered person must ensure that at all times suitably qualified ,competent and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of service users. (previous timescale not met - 01/03/05) The registered person must ensure that a photograph, identification and two references are held within the home. The registered manager and staff must receive specific training and guidance in relation to alcohol dependency in accordance with the National Treatment Agency guidance. An annual report stating the results of service user and other stakeholder surveys must be published and a copy sent to DS0000000878.V258448.R01.S.doc 18/12/05 18/12/05 18/12/05 18/12/05 18/12/05 18/12/05 18/12/05 18/12/05 18/12/05 Anchor House Version 5.0 Page 26 17 YA40 17 CSCI. (previous timescale not met – 01/03/05) The registered person must give 18/12/05 consideration to the alcohol policy and the appropriateness of the current registration. 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 Refer to Standard YA1 YA24 Good Practice Recommendations The long-term purpose of the home should be reviewed in the light of the ageing service user group. The carpets in Rooms 203 and 217 should be replaced. Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Anchor House DS0000000878.V258448.R01.S.doc Version 5.0 Page 28 - 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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