Inspection on 28/04/08 for Anchor House

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Good service.

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

Similar services:

Honeybourne House

32 Beaumont Way

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Anchor House 1 Evering Avenue Parkstone Poole Dorset BH12 4JF Lead Inspector Tracey Cockburn Key Unannounced Inspection 28th April 2008 10:00 Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 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 DS0000070522.V361993.R01.S.doc Version 5.2 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 DS0000070522.V361993.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anchor House Address 1 Evering Avenue Parkstone Poole Dorset BH12 4JF 01202 735914 01202 735914 anchor.house@harbourcare.co.uk 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 Eve Mary Went t/a Harbour Care Mrs Tracy Anne Ison Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users that can be accommodated is 7. Date of last inspection New Service registered in October 2007 Brief Description of the Service: Anchor House is a new service registered to provide support and care to up to 7 people. The home is situated in a quiet street close to public transport routes into both Poole and neighbouring Bournemouth. The home is a detached chalet bungalow, which has been refurbished to a high standard and provides spacious accommodation on the ground and first floor. There is parking at the front of the home and there is a patio and garden at the rear. There is access to the garden via the kitchen door and 2 of the ground floor bedrooms. There are patio doors in the lounge, which at present are not used, as the patio outside these doors has not yet been laid. All 7 bedrooms are singles those on the 1st floor have en-suite facilities. The ground floor rooms have access to 2 bathrooms and 1 wet room. There is a large lounge with overhead tracking hoist, kitchen with dining area and large garden with access from patio doors in 2 bedrooms on the ground floor. The provider, Harbour care, has a number of other services in area. The weekly fees range from £900.00 to £1800.00. This information was correct on 28/04/08. Further information on fees and contracts can be found on the Office of Fair Trading website: www.oft.org.uk Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was the first key inspection of a new service. At the time of the visit there were 2 people who live in the service present throughout the day. The manager and 1 other member of staff were also present. Survey forms were sent to the service in preparation for the inspection. Relatives, carers or advocates returned 3 survey forms. People who use the service returned 3 survey forms and staff that work in the service returned 3 survey forms. People who use the service had the help of people who know them well to complete the survey forms. 1 person who responded to the survey said: “ the decision to move to Anchor House was made on my behalf by my parents, supported by Dorset Advocacy and social services” 1 relative, carer or advocate who returned a survey forms said: “ Anchor House appears to be a well run and happy care home” Another relative, carer or advocate said: “ we are impressed with the skill and expertise of all the staff” Staff who returned survey forms said: “encourages staff moral, the staff work well as a team” The manager also submitted an Annual Quality Assurance Assessment before the inspection and this document contributed to the planning of the inspection. During the visit a tour of the premises took place. Care documents were seen, as well as staff files, training records, policies and procedures and safety information such as records of fire checks and incidents. What the service does well: People who are considering using this service have a detailed assessment of their needs which means that the service is very clear whether or not it has the right staffing, skills and support needed before offering someone a service. People living in the service have an individual person centred plan detailing their needs and goals and how they like to be supported. People are supported to make choices in their daily lives by staff that understand them. Risk assessments support each person in their wish to have an independent life. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 6 The service is developing activities, which meet each person’s wishes and aspirations. People who live in the service are part of the local community and do every day ordinary activities. People who use the service are able to maintain contact with their families and friends. 1 relative said “ the manager and staff keep in regular contact with us” “ we are made to feel very welcome when we visit” During the inspection staff were observed being respectful of people’s choices such as preferred form of address and not entering their rooms without permission. People living in the home are offered a healthy diet and the manager is responsive to changing nutritional needs of the people using the service. The service clearly records how people like and need to be supported and provides clear information on the individual behaviours, which indicate how someone is feeling. There is good written evidence of how people are supported to have their physical and emotional health needs met. The manager makes every effort to ensure that people’s views are listened to and acted upon. Staff have received the training they need to understand how to protect people living in the service from abuse. The service provides a very high standard of accommodation with exceptional attention to detail to ensure that the people living in the service feel like it is their own home. The home is clean which demonstrates that the people working in the home take pride in the care and support they are providing. Staff working in the service are competent and qualified to do the job. Recruitment procedures ensure that people living in the home are protected. The home is run by a manager who takes their role and responsibilities very seriously and wants to deliver a good service to the people living there. Quality assurance systems are in place, which means that people will be able to express their views about the service and how they want it to develop. Appropriate checks are completed to ensure that the health, safety and welfare of people living in the service are protected. What has improved since the last inspection? This is the first key inspection of this new service, which first registered with the commission in October 2007. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 8 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 DS0000070522.V361993.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Detailed assessments mean that the service only offers a place to people when it is confident staff have the skills to support them. EVIDENCE: In the entrance hall there is an information file which contains a copy of the mental capacity act and a copy of ‘our health our care our say’ both are in easy read formats. The entrance hall also contains a notice board with “ Welcome to Anchor House” There are photographs of the people who live there as well as photographs of the people work there. In the Annual Quality Assurance Assessment submitted by the manager they stated “We put together a transition file for each service user prior to admission and all records are kept on file.” 1 file was looked at, there was a detailed assessment containing a health and social care assessment. The manager says that they would like to have a longer transition period and are negotiating this with the primary care trust. At present staff work with the carers before a person moves in. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 10 They visit to get to know the person, find out how they like to be supported and start to develop a relationship with them. They find out how each person likes to be communicated with and their individual communication methods. The manager sees this as a very important part of the process. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have individual plans of care, which reflect their changing needs and goals. People living in this service are making decisions about their lives with support and risk assessments support an independent lifestyle. EVIDENCE: In the annual quality assurance assessment submitted by the manager she states: “As our services users have communication difficulties we ask their families, friends and advocate a lot of questions. We also observe service users body language and reactions to try and understand what the service users are feeling. We also use various different communication aids to support the service users with expressing their views.” The manager also said: “We have changed our portable floor hoist to a ceiling track hoist as service users expressed her dislike to the mobile hoist.” Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 12 The manager also went on to say in the annual quality assurance assessment; “due to the communication difficulties that our service users have we offer various different communication aids, such as flash cards and makaton, we also offer them choices by showing them various objects to choose from. One of our staff members is currently training to be a total communication coordinator and we also have in place a communication profile for each services user. This assists the staff will identifying the service user’s choices that they are making and in identifying their needs.” Since the AQAA was submitted the home now has a Total communication coordinator. The manager explained that over the next few weeks they are planning to take a digital camera out with them taking pictures of each person’s GP surgery, as well as other locations which are important to each person in the home and develop their own unique communication book. Both files seen contained the same layout of information there is an identify form, hospital grab sheet, general care plan, person centred plan and communication profile, goals and activity chart, specific care plans, risk assessments, daily record sheets, health professional notes, health action plan. The support plan provides a description of the morning routine including how they are supported with personal care, how they like to eat their breakfast and any other aspects of their routine such as resting on their bed in the afternoon. There are specific care plans which detail what action to take if an individual has a seizure, the care plan is very specific about warning signs, when to call an ambulance, when to administer medication. On 1 file there was not enough information on why medication had to be given in a certain way, although staff were aware of why and the procedure they had to follow, it was not written clearly. All the care plans seen detail the equipment needed for example, at meal times there is information for staff on the positioning of the person’s chair, the level of assistance they need, the type of cutlery they use. During the visit staff were observed following the information as laid out in the care plans. People living in the service are able to express themselves and have their needs understood, decisions about their lives are take with their circles of support, which are people that know them well. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about the life they lead, taking part in activities, which interest them in the local community. People using this service maintain contact with people important to them. People living in the service work with staff to maintain healthy diet. EVIDENCE: In the annual quality assurance assessment completed by the manager it states “We encourage the service users to express their individuality by encouraging them to decorate their rooms to reflect their personalities; we also support the service users to access groups, religious services if the so choose. We have equipped the home to suit the specific needs of the service users.” The manager said that 2 people attend a local day centre at the moment this is 5 days a week which they are hoping to reduce to 3 through liaising with the primary care trust and parents. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 14 Another person living in the service is also reducing their attendance at a day centre and choosing to go out with staff from anchor House. 3 people currently have advocates. 1 person has had one requested. Each person has information in their room of who their key worker is with a picture; there is also information in easy read format about how to complain and how to contact the commission. There are lots of DVD’s in the lounge for people to watch. 1 person asked by staff if they wanted to watch something, which their file said was one of their favourites. In survey forms returned by relatives, advocates or carers, they all said that they are made to feel very welcome when they phone or visit. Information in individual files is very person centred which means the focus is very much on how each person likes to be supported. During the site visit the staff were observed involving people who live in the service in day-to-day activities. 1 member of staff was preparing lunch and while she was doing this she continued her conversation with the 1 of the people living in the home. People living in the home are offered a varied menu, which takes into account their individual preferences. People are supported to eat their meals in the way they like and there is detailed information kept on the nutritional needs of each person. The cupboards were stocked with a variety of tins and dry foods. There was fresh fruit and vegetables in the fridge and the freezer was also well stocked. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A person centred approach is used by the service to support the personal, physical and emotional needs of the people living in the home. The home’s policy, procedure and training for dealing with medicines protect the people living in the service. EVIDENCE: Care plans record in detail how people like and need to be supported. The information is written in a person centred way from the individual’s perspective about what they need to be safe. 2 of the people living in the service are supported by staff that have known them a long time, staff feel that this has helped in the transition into living in the new home. The service uses a key worker system, people who returned survey forms said that the staff were helpful and contacted them with information. Each person has information in their all about me information detailing activities which interest them as well as activities they might like to try. People in the home have access to a vehicle so they are able to go out and about. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 16 The manager works the roster flexibly to enable to people to go out when they want. Service users personal care records, health care records and service users monthly reports written by the key workers. 1 file contained detailed information on the action taken when the weight of 1 person dropped this had already been identified in the care plan as a risk area and the action taken was swift. The goal of the care plan is to maintain a good weight and the plan also states what is considered a good weight and at what point the persons weight is worrying. The care plan is very specific, detailing how to encourage the person to eat. There is also information on how to record what has been eaten and how the person is when they eat. There is evidence of consultation with health care professionals. This level of detail is also repeated in care plans to support specific medical conditions. In both the files there was recording of visits by speech and language therapist as well as visits to the optician and chiropodist. The manager states in the AQAA: “We are looking into accessing an aromatherapies, music therapy sessions within the home and accessing a hydrotherapy pool outside of the home”. During the inspection staff were observed dispensing medication to some one who lives in the home. There is a small metal cabinet in each person’s room, which is lockable and contains their medication in a monitored dosage system. Two members of staff complete this task, checking and countersigning the records. 1 person who at times is reluctant to take medication has it given in food, there was some information in the care plan about why this was necessary and a risk assessment in place and healthcare professionals had been consulted as well as representatives of the individual. The manager said that the medication is not crushed or altered in any way. The manager was aware of the guidance on covert medication. However greater clarity in the care plan is necessary. (see standard 6) Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns and have access to a complaints procedure. Safeguarding training for staff and clear procedures means that staff have the information they need to ensure people are protected from abuse. EVIDENCE: In the company’s complaints policy there is a statement, which says: ‘ it is the company’s policy to welcome complaints and look upon them as an opportunity to learn, adapt, improve…’ The manager said that oral complaints are taken seriously and recorded and action taken. 1 survey form returned by a relative stated that they knew how to make a complaint and that they were approached by the manager to talk about any concerns or worries they had. 1 person who uses the service said that their parents would know how to complain. At the time of the inspection there were no safeguarding investigations taking place. Staff have received safeguarding training and in 2 staff files there were workbooks, which they were in the process of working through. In the annual quality assurance assessment submitted by the manager she states; “We could reformat the concerns and complaints procedure to a more service user’s friendly format, i.e. by using widgets.” Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People live in an environment, which is modern, comfortable and focused on their needs. The home is clean. EVIDENCE: The service is a large detached building set in its own grounds with car parking to the front. It is situated in a quiet area of Poole, within close reach of a wide range of amenities. There is garden to the side and rear of the property. The side garden has yet to be landscaped. A patio area has been laid to the rear, accessible from two bedrooms, kitchen and lounge. The home provides a physical environment, which is appropriate to the specific needs of the people living there. There is an overhead-tracking hoist, which runs the full length of the lounge. The lounge is spacious and there are numerous beanbags for people with physical disabilities to relax in. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 19 The ground floor is accessible and at the time of the site visit a decision had been taken to put in a through floor lift, so that the first floor is also accessible. All the rooms are single and spacious and they exceed the standard required. All fixtures and fitting are to a high standard and finish. The ground floor accommodation comprises a lounge, dining area attached to the kitchen, staff/visitors WC, laundry/utility room, office, one large bathroom, including WC, one large shower room with WC (with wall mounted rail). Both WCs are suitable for disabled users. The bath/shower rooms have been purpose-built for three of the people living in the home and include tracking hoist facilities. Both rooms are spacious and positioning of facilities is designed to enable both wheelchair users and tracking hoist users to access them. The first floor comprises three bedrooms, all of which have spacious en-suite shower, wash-hand basin and WC facilities. The rooms have slightly sloping ceilings in some sections. The annual quality assurance assessment completed by the manager states; “after assessing the needs and disabilities of our service users we have furnished the lounge with bean bags and floor mats and an over head ceiling track hoist rather than with sofa’s and tables etc. as we feel it is important that the service users have complete freedom in their own home” All radiators have thermostatic controls to enable individuals to regulate the temperature. Radiators are of a type with a low heat surface. Window restrictors are not in place at first floor level. The manager is aware that risk assessments will need to be completed for anyone moving into rooms on the 1st floor. There is purpose-built wheelchair ramped access to the front door. All ground floor areas are accessible to wheel-chair users except the laundry/utility room which is too narrow for such a purpose. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the service are supported by staff that are part of a robust recruitment and training system. Training needs are identified and linked to the needs of the people living in the service. EVIDENCE: During the site visit staff were observed with 2 people who live in the service, they spent their time, talking and engaging with each person. They were seen supporting them to complete daily living tasks such as support at meal times and assisting with medication. Through observation and reading the care plans it was clear that staff were very familiar with each persons needs and how they communicated their feelings. 2 staff were seen as part of the site visit, both files contained information required such as 2 references, proof of identity, Criminal Records Bureau disclosure. There was evidence in both files that staff had signed to say they had been given the General Social Care Council code of conduct. There were also copies of their contract and terms and conditions. The service has not used any agency staff since opening. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 21 There was a letter on 1 persons file from the service manager thanking them for their hard work. 5 members of staff currently have national vocational qualification (NVQ) at level 2 and a further 2 staff are working towards it. There is 7 fulltime staff and 3 part time staff working in the home at the time of the site visit there were 4 people living in the service. There were some gaps in the training records of staff in the service. The manager had arranged for the staff to be put on training courses, when she noted the gaps on a recent audit. The manager undertook this audit when she realised that training had not been taking place and “ I knew we would be inspected soon”. The provider has someone responsible for all training; there is evidence that this has not been working effectively. Staff records show that mandatory training courses have been either completed in the last few weeks or arranged and staff are booked on to courses in first Aid Training, Food Hygiene, moving and handling in the next month. 2 people are receiving update training in Epilepsy. 1 member of staff has been delegated the responsibility of ensuring the following: - first aid boxes are checked - fire alarms are tested - water temperatures checked - medication is re ordered - Health and safety checks are completed The member of staff said they are very happy to complete these tasks. In the Annual Quality assurance assessment written by the manager she said; “we have a very strong staff team who are very willing to help and support each other. all of our staff receive a comprehensive in house induction along side monthly staff supervision and an on going training programme. With in the home we also mentor Bournemouth learning disabilities nursing students, this help us to ensure that we are up to date with current practices.” Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The manager of the service has a clear vision of the home and a passion to deliver a high quality person centred service. Systems are in place to ensure that the people living in the service have a voice in how it develops. EVIDENCE: The manager Tracy Ison has attained National Vocational Qualification level 3 in care, the Registered Manager’s Award (RMA) and has commenced preparation for the National Vocational Qualification level 4 in care. She has also completed the foundation level for the Learning Disabilities Award Framework (LDAF). She has attended a wide range of courses over the past three years that relate to care practice and health and safety. The manager has also completed training on person centred planning. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 23 The provider has a corporate quality assurance system in place, the manager demonstrated during the inspection that the people living in the service are asked their opinion on aspects of the home and are listened to. Several people who responded to survey forms sent said that the manager has said to them that they are welcome to make any comments about the service and talk to the manager about changes. The manager has also said that she welcomes comments on how to improve the service. As the service has only been open 6 months the process of self-monitoring is only beginning. Windows on the first floor are not restricted but will be risk assessed as people move into those rooms. The COSHH (Control of substances hazardous to health) cupboard was securely locked. The insurance certificate was displayed and up to date and valid until 18/3/09. The manager keeps a file with all the regulations 26 visit to the home. The last visit was 09/03/08. A test of the fire alarm was completed during the site visit. All fire records were up to date. The service has a fire risk assessment. Staff are receiving induction and foundation training using the skills for care standards. Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations Care plans should contain information on why a particular action is necessary such as administering medication in a certain way to ensure that individuals are protected and staff understand the importance of doing the task in a specific way. The manager should audit the training records of all staff as part of supervision to ensure that all training needs are being met. 2 YA35 Anchor House DS0000070522.V361993.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000070522.V361993.R01.S.doc Version 5.2 Page 27 - 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. 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