Inspection on 02/01/08 for Anchor Lodge

This inspection was carried out on 2nd January 2008.

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

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

Anchor Lodge 31/01/07

Anchor Lodge 15/05/06

Anchor Lodge 06/03/06

Anchor Lodge 31/10/05

Anchor Lodge 02/03/05

Anchor Lodge 28/09/04

Anchor Lodge 28/04/04

Anchor Lodge 12/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Anchor Lodge Cliff Parade Walton-on-Naze Essex CO14 8HB Lead Inspector Ray Finney Unannounced Inspection 2nd January 2008 09:30 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 Anchor Lodge DS0000036541.V357183.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 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. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anchor Lodge Address Cliff Parade Walton-on-Naze Essex CO14 8HB 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) 01255 850710 01255 850710 chez40uk@yahoo.co.uk www.anchor-lodge.co.uk Mr Farooq Mohammed Mrs Uzaira Farooq Manager post vacant Care Home 14 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (3), Old age, not falling within any other of places category (14) Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 14 persons) Three persons, aged 65 years and over, who require care by reason of dementia, whose names were provided to the Commission in April 2005 One person, under the age of 65 years, who requires care by reason of Korsakoff Syndrome (dementia) whose name was provided to the Commission in March 2004 31st January 2007 Date of last inspection Brief Description of the Service: Anchor Lodge is an established care home situated in a residential area of Walton on Naze. Local shops, post office, library, churches and leisure facilities are all found in the town. The detached property overlooks the seafront with views of the beach and the sea from the home. There is a front garden in which people can sit. There is off road parking to the rear and side of the home. Accommodation is in twelve single rooms and one double room, over three floors. Access to the upper floors is by means of a passenger lift and stairs. In recent years alterations and additions have been made to the bedroom accommodation, all now having en suite facilities of wash hand basin and toilet. Communal areas are a ground floor main lounge and a small sun lounge. There is also a small first floor lounge with sea views. The home charges between £375.00 and £650.00 a week for the service they provide. Other services such as hairdressing, chiropody and aromatherapy are available at an additional charge. This information was given to us in January 2008. Information about the home can be obtained by contacting the manager. Inspection reports are available from the home and from the CSCI website www.csci.org.uk Anchor Lodge DS0000036541.V357183.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. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed surveys were received from members of staff, people living in the home and their relatives. The manager completed an Annual Quality Assurance Assessment with information about the home. This document will be referred to as the AQAA throughout the report. A visit to the home took place on 2nd January 2008 and included a tour of the premises, discussions with people living in the home, the manager, members of staff and a visiting healthcare professional. Observations of how members of staff interact and communicate with people living there have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and the inspector was given every assistance from the manager and the staff team. What the service does well: People living in the home and their relatives are complimentary about the environment and the care provided. One relative said, “Service is good” and someone living in the home said, “This home is a very nice home to live”. Overall Anchor Lodge provides a clean, homely environment and is generally well maintained and decorated. The menu in the home provides people with a well-balanced and varied diet. Staff provide good home cooked food that is enjoyed by people living in the home. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 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 Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at Anchor Lodge receive sufficient information about the home and may be confident their needs will be assessed before admission. EVIDENCE: The AQAA states that Anchor Lodge provides a statement of purpose which sets out the aims and objectives of the home. A copy of the service user’s guide and terms and conditions are given to all residents when they move into the home. Records examined confirm that people receive appropriate information about the home before they choose to live there. The manager also states that they “invite people to come and spend a day at the home before making their final decision and have a meal with us to sample the food”. A survey returned by someone living in the home confirmed that they chose the home, “with consultation with the family and pre-visits”. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 9 In response to a requirement made in the previous inspection report, an action plan received states that each resident will be given a contract when moving in to the home and the manager will discuss with residents and their representatives to confirm that they understand the terms and conditions. The manager confirmed that this requirement has been met and all those living in the home now have a written contract stating the terms and conditions with the home. A sample of three records examined all confirm that there are contracts in place that are signed by the resident or their representative. The AQAA states that a needs assessment is done on all new prospective residents before they move into the home to make sure that they can meet their needs. The pre-assessments have been revised and now includes more information. A sample of three people’s records was examined. All contain a comprehensive assessment of needs that is cross referenced to the care plans. There are separate risk assessments around moving and handling, falls, pressure sores and mental health and there are ‘Risk Reduction Plans’ in place to minimise identified risks. Records examined confirm that risk assessments are reviewed three-monthly. People choosing to move to Anchor Lodge may be confident that their needs will be assessed before they move in. National Minimum Standard 6 does not apply as Anchor Lodge does not offer intermediate care. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service receive the care they need based on detailed care plans. EVIDENCE: Considerable work has been done since the last inspection to improve the care plans. The AQAA states that they “put a care plan in place using the pre assessment information” and that people living in the home are involved in putting the care plan together if they are able to do so. All care plans include risk assessments and are evaluated on a monthly basis to record changes to the residents needs. Records examined confirm that care plans have improved. Three care plans were examined and each has a photograph of the resident. All contain a comprehensive profile that includes a medical history, wishes around end of life, finances, preferences around clothing, smoking, sexuality, personal hygiene, dietary requirements including likes, dislikes and allergies, where the person likes to eat meals and the level of assistance required. Care Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 11 plans contain sufficient detail to ensure that staff will be able to support people in ways that they prefer. Staff spoken with are able to demonstrate a good awareness of people’s needs. One member of staff who completed a survey said they “Support the needs of each person individually” and “Treat everyone as individuals and not just their illnesses”. Another member of staff said, “The management and the staff are trying their best to meet the needs of the service users by giving them quality care”. People living in the home are also positive about the care they receive. One said, “I am very happy. Always a good hairdresser and chiropodist comes in”. A relative who completed a survey said, “It is a very friendly home and everybody seems to be very happy. My relative is being looked after very well and they are very happy”. The AQAA states that all those living in the home have access to relevant healthcare services, including chiropodist, district nurses, doctors, Community Psychiatric Nurses and dentists. Regular eye testing is done in the home. This is confirmed in the records examined. Evidence was examined of hospital visits, District Nurse visits and dental appointments. A visiting healthcare professional spoken with on the day of the inspection, said that they do not need to come to Anchor Lodge very often, because there is not a high need for community nursing services for the people who live there. The visiting healthcare professional also confirmed that community nursing services are informed promptly if their services are required and any advice is followed. People living in Anchor Lodge may be confident that they will receive input from relevant healthcare professionals according to their healthcare needs. The home uses a Monitored Dose System for medication that is dispensed by a local pharmacy and delivered to the home. The storage and administration of medication was examined. Medicines are stored in a securely locked trolley. The manager said that any medications requiring storage at controlled temperature would be kept in a sealed box in the fridge, although none were in use at time of inspection. Medication that is not in dispensed blister packs is clearly marked with the date that it is opened. The storage of medication is well organised. Medication Administration Record (MAR) sheets examined were all completed correctly and contain photographs to minimise risk of errors and protect people living in the home. The manager said that she audits medication regularly and this is confirmed by audit sheets examined. There are no controlled drugs in use at present, but there is a system in place for the storage and recording of controlled drugs. The manager is able to demonstrate a good awareness of her responsibilities around safe storage and administration of medication. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 12 The AQAA states that all staff dealing with medication have completed a training course and are competent in the administration of medication. There is improved in-house training. Records examined confirm that staff have received training around the safe storage and administration of medication. Overall there are good procedures in place around the storage, recording and administration of medication, which should ensure people are protected. The manager states in the AQAA that people are treated with respect at all times and are addressed by staff by their chosen name. Observations on the day of the inspection confirm that staff are courteous and treat people with respect. Staff spoken with demonstrate a positive attitude and an affection for the people they are caring for. At the time of the last inspection a requirement was made that un-obscured windows between a corridor and residents rooms must be covered. This was completed promptly and a tour of the premises confirmed that blinds have been put up in a bedroom room where there is a window looking onto the corridor. This will ensure that privacy and dignity are maintained for anyone using this room. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Anchor Lodge have opportunities to participate in activities that are appropriate to their needs and they are supported to build and maintain relationships. People have varied diet that they enjoy. EVIDENCE: Information provided in the AQAA states that people are consulted about what they would like to do on a daily basis and are encouraged to carry on with the social activities that they did before moving in to Anchor Lodge. Care plans contain information about the activities that people like to take part in. People enjoy bingo and music; one person particularly enjoys singing Frank Sinatra songs. Members of staff spoken with know people’s likes and dislikes well. Although there were no organised activities taking place on the day of this inspection, people were socialising and the atmosphere throughout the home was relaxed. Although the manager and staff team encourage people to keep active, their choices are respected. One person chooses not to join in activities and prefers to remain in their room reading and watching television. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 14 The home is situated just a few yards from the beach and the manager said that people enjoy going for walks when the weather permits. There are always a minimum of two staff on duty and for three days a week the manager is supernumerary so people are able to get out. Rotas examined and observations on the day of the inspection confirm that staffing levels are sufficient to ensure people receive the support they need to take part in their chosen activities. The manager said that people can have visitors at any time and receive them in any of the communal rooms or in the privacy of their own rooms. A relative who completed a survey said, “Visitors are made so welcome”. Records examined confirm that people are supported to meet their religious preferences. A local vicar comes in monthly so that people can have Holy Communion and some people go out to church weekly. The menus were examined and confirm that there is always a choice of hot meals available including chicken, fish and a variety of other traditional meals. The cook spoken with said they ask people in the morning what their preferences are for lunch. There are fresh fruit and vegetables available daily and food stocks are delivered from the supermarket weekly. Care plans contain information about peoples dietary requirements including likes, dislikes, allergies, where the person likes to eat their meals and the level of assistance required. The AQAA states that people are consulted about the choice of food on the menu and any comments are taken into account. Residents can have their meals in the dining room or if they prefer in the privacy of their own rooms. On the day of the inspection one person chose to eat in their room. A survey completed by someone living in the home said that the food is “Very good”. Overall, the varied and nutritious range of meals available is enjoyed by the people who live in Anchor Lodge. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. There are procedures in place to protect the people who live there. EVIDENCE: On the day of the inspection concerns and complaints were discussed with the manager, who is able to demonstrate a good awareness of the importance of dealing with minor concerns as well as formal complaints. The AQAA states that Anchor Lodge has a complaints policy and protection policy in place and staff are aware they should work to these; residents and families are made aware that should they wish to make a complaint it would be taken seriously. The complaints book was examined and contains records of minor concerns and how they have been dealt with. Records are also available of numerous compliments received from relatives expressing thanks for the good standard of care provided by the staff at Anchor Lodge. The AQAA states that the complaints policy has been reviewed in the past year and a copy of the policy and how to report a complaint to CSCI is displayed on the notice board and this was seen on a tour of the premises. A relative who completed a survey confirmed that they know how to make a complaint if they wish and said that the information is on a “Poster on the board in the home”. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 16 A requirement was left at the last inspection that people should be supported to exercise their right to vote in elections. This was discussed with the manager, who confirms that all those living in the home are now registered for postal votes so they are able to participate in elections. The AQAA states that all staff are aware of the protection of vulnerable adults and how to respond to any form of suspected abuse; staff training about abuse has been attended. The recruitment process has been improved and enhanced Criminal Record Bureau Checks (CRB) are now obtained before employing staff. A sample of records examined confirmed that CRB certificates are in place. Personnel records also confirm that staff have received training around safeguarding matters. Staff spoken with are able to demonstrate an awareness of their responsibilities around safeguarding vulnerable people. People are protected from financial abuse by the procedures in place for supporting people with finances. The AQAA states that “All residents money that is looked after by the home is kept securely in a locked safe and residents have access to it when they need it”. Records examined confirm people are supported appropriately around their finances (see evidence for National Minimum Standard 35). Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Anchor Lodge benefit from a comfortable environment that is mainly well-maintained and clean, although some improvements need to be made to ensure people have choice and are safe. EVIDENCE: The AQAA states “We keep our home clean and tidy and well decorated”. There is a handy man to carry out minor repairs and a maintanence book is in place to report work that needs to be done. The manager said this book is checked weekly to ensure work is completed. A gardener visits once a fortnight to keep the grounds outside neat and tidy. A tour of the premises confirmed that there is a good standard of cleanliness throughout the home. The communal rooms are bright and comfortable. At the time of the inspection the lounge still had Christmas decorations up including a well-decorated tree and the home still looked very festive. The AQAA states that they have a Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 18 “lovely view for our residents to look out at through the French doors in the lounge”. A tour of the premises showed that bedrooms are bright and airy, some with sea views. All bedrooms are individual and show evidence of personal possessions such as ornaments and photographs. Furnishings are domestic and comfortable and people living in Anchor Lodge benefit from the homely surroundings. As reported at the last inspection, the ramp outside the French doors leading to the garden is steep and may present a risk of falls to anyone who is elderly or unsteady. A discussion with the manager confirmed that there is other safe access to the garden. However, although people are not accessing the garden at present because of the cold, when the weather becomes better people may like to have the patio doors open and this would pose a risk. Thought should be given to replacing the ramp with one that has a more gradual slope and a handrail. The dining room is small, but at present there are only nine people living in the home and one person does not like to spend any time in communal areas, so the dining room can accommodate all those living there at one sitting. In the event of vacant rooms being occupied there would not be room for everyone in the dining room. This was discussed with the manager who felt they would be able to manage the situation by having more than one sitting for meals. The bathroom on the ground floor has an assisted bath and the manager said this is the bathroom that is mainly used. The bathroom on the second floor is not used but is kept clean and is in working order. There is a shower room on the first floor; only one person likes to use this shower room, which is not currently in use as the shower is being replaced. There is a toilet and shower on the ground floor next to the assisted bathroom but the manager says that this shower is not used and they are considering alternative uses for the room. A tour of the premises showed that the light in this shower room needs to be replaced. Overall the bathing facilities are appropriate for the number of people living in the home, although the manager should ensure that planned repairs to the shower are completed promptly so that anyone who wishes to have a shower rather than a bath is able to do so. The AQAA states that staff have attended Health & Safety training that includes an awareness of infection control. Personnel records confirm that staff have received Health & Safety training. It was seen on a tour of the premises that there is a good standard of hygiene throughout the home, with no offensive odours. The laundry has appropriate washing and drying machines for the size of the home. There is a hatch between the laundry and the bathroom so that soiled linen does not have to be transported through areas where food is prepared. The laundry room itself, although clean, is in need of renovation. The flooring, walls and cupboards are old and damaged and need to be improved. In Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 19 particular the flooring should have an impermeable finish and walls should be easily cleaned if people living in the home are to be protected by good infection control. Risk assessments are in place and water temperatures are being checked to minimise risks to vulnerable people. However, some radiators could present a risk, as they remain unguarded. The action plan received from the home stated that the issue of uncovered radiators was being dealt with and the manager said that quotations have been sought for radiator covers. It is essential that the risks around uncovered radiators are assessed to ensure the safety of people living in Anchor Lodge. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Anchor Lodge benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed. EVIDENCE: In a discussion with the manager she said that they use the Residential Forum dependency tool to assess staffing levels according to the needs of people living in Anchor Lodge. Rotas examined confirm that there are always two care staff on per shift and a cook during the day. The manager also works some shifts but for three days a week is not on shift and carries out her management role. At night there are two staff on duty, one working an awake night shift and the other as a sleep-in to be on call if necessary. The sleep-in staff also helps with the morning routine. Observations on the day of the inspection visit confirm that staffing levels appear sufficient to meet the needs of people living in the home. Completed surveys contain positive comments about the staff. One relative who completed a survey said, “The staff seem to be very caring, kind and happy”. Residents are also complimentary about the staff. One said, “Good staff here. Been in nursing myself so I know good care” and another “Good staff all round, day and night”. The AQAA states that they meet the National Minimum Standard of having 50 with National Vocational Qualification (NVQ) at level 2 or above. The Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 21 manager said that out of a total of ten care staff all but two have either completed or are in the process of doing NVQ at level 2 or above. The sample of personnel records examined contains evidence of NVQ awards. The AQAA states that they only employ staff after receiving two written references and carrying out Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. Personnel records examined confirm that appropriate checks are carried out and relevant documentation is in place. Improvements have been made since the last inspection. The files are better organised and have a check list on the front. The recruitment process is now more robust and people living in the home can be confident that they are protected by the home’s procedures for recruiting staff. The staff training planner indicates that all staff have received training around the Protection of Vulnerable Adults. Staff training certificates are kept in personnel files. Records examined confirm that staff have received training in dementia, death, medication, pressure sore management and continence. The manager said that dementia training is ongoing. Staff spoken with were able to demonstrate a good knowledge of their responsibilities and ensuring they follow good practices. Observations on the day of the inspection also confirm that staff carry out their roles in a caring and professional manner. Overall people living in Anchor Lodge benefit from being cared for by a competent staff team. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Anchor Lodge is competently managed and run in the best interests of the people who live there. The health and safety of individuals living and working there is promoted and protected. EVIDENCE: Records examined confirm that the manager is suitably qualified to run the home. She has a National Vocational Qualification at Level 4 in care and has obtained the Registered Manager’s Award (RMA). It is apparent that the manager uses the supernumerary hours when she is not on shift well to improve and update the record keeping in Anchor Lodge. There have been significant improvements in the management of the home since the last key inspection. The manager has not yet been registered with us at the Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 23 Commission and a discussion with the manager confirmed that the proprietors will be dealing with the application for registration. Completed surveys from people using the service are complimentary about the way the home is run. A relative said, the “New manager is good and lovely with the clients” and a resident stated, the “Manager is very good”. On the day of the home’s inspection the Quality Assurance system was discussed with the manager. Records confirm that there is a process in place for gaining the views of people using the service. Surveys were sent to relatives and a few were completed and returned. Records examined also confirm that staff meetings and residents’ meetings take place. The manager was able to explain some of the things that they have done in response to issues that have been raised by residents or their relatives. Minor concerns and how they are resolved are also well documented. Overall the manager of Anchor Lodge is able to demonstrate that the service responds to people’s views and wishes. However, the process should be developed further so that all this information is pulled together to form an action plan for the home. The manager confirmed that they do not manage anyone’s finances. One person manages their own finances independently; otherwise relatives or legal professionals manage people’s money on their behalf. There is a process in place to support people with small amounts of pocket money. A sample of three finance records examined confirm that the process is robust to ensure people living at Anchor Lodge are protected. Individual records and small amounts of money are stored separately and securely. Receipts are available and documents examined are in order. As at the last inspection, there continues to be a process in place for the supervision of members of staff. The manager states in the AQAA that “the home is run in the best interest of the residents, staff are supervised”. This is confirmed in the sample of personnel files examined, which contain evidence of recent supervision. Staff spoken with on the day of the inspection feel wellsupported by the manager. Staff who receive regular supervision feel well supported and may be confident they are doing their job well. This should enable them to provide a good quality of care to meet people’s needs effectively. People living in the home and their relatives can have confidence in the ability of staff to meet their needs. There have been improvements in the recording of health and safety procedures since the last inspection. The manager has put a maintenance folder in place and a Health & Safety folder, which contains certificates relating to systems within the home. Records examined confirm that water temperature checks are being carried out regularly and there are recent Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 24 certificates in place relating to hoists, the lift, portable electrical appliances and fire equipment. A new heating system has been installed. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 25 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 2 X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 26 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 OP25 Regulation 13(4)(c) Requirement The registered person must ensure that risks around unguarded radiators are assessed. THIS IS A REPEAT REQUIREMENT Timescale for action 28/02/08 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. 3. Refer to Standard OP19 OP21 OP26 Good Practice Recommendations The registered person should ensure that the ramp leading from the lounge French windows is safe for people in the home to use. The registered person should ensure that the broken shower is replaced so that people in the home may have their preferred choice of bathing facilities. The registered person should ensure that the laundry floors and walls have a finish that is readily cleanable and the hand washing facilities are improved so that staff and people living in the home are protected by good infection control. DS0000036541.V357183.R01.S.doc Version 5.2 Page 27 Anchor Lodge 4. OP33 The Quality Assurance process should be developed further to ensure there is an action plan around what they will do in response to the information they receive from people using the service. Anchor Lodge DS0000036541.V357183.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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