Inspection on 06/03/06 for Anchor Lodge

This inspection was carried out on 6th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 02/01/08

Anchor Lodge 31/01/07

Anchor Lodge 15/05/06

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 Sara Naylor-Wild Unannounced Inspection 11:30 6 March 2006 th 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.V286030.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 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 www.anchor-lodge.co.uk Mr Farooq Mohammed Mrs Uzaira Farooq Care Home 14 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (2), Old age, not falling within any other of places category (14) Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 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) Two 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 October 2005 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 service users 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 is via a staircase or passenger lift. 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 found on the ground and second floor and comprise of a lounge, sun lounge, dining room and a small first floor lounge with sea views. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days on 6th March and 29th March 2006. This additional appointment provided opportunity for the inspector to meet with the proprietor Uzaria Farooq at the home in order to access records held securely in the office. What the service does well: What has improved since the last inspection? Care plans had been re-launched since the previous inspection, with a person centred format based on the Alzheimer’s Society documentation in place for all eight service users. The documents contained comprehensive information in respect of the service users’ daily lives and expectations. At an introductory level these will assist staff in understanding how best to support service users, and provide a platform from which to develop their knowledge of individuals’ strengths and needs. The premises were undergoing an extensive refurbishment to the ground floor communal areas with the addition of French windows to the lounge, providing views across the sea front. The proprietor identified further work planned to individual service users’ rooms, all of which will enhance the environment and the service users’ experiences. New staff with a background in care had been recruited to the service; this continues to build on the staff teams competencies and experience. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. The statement of purpose and service users guides are updated. The terms and conditions were not available in the home. EVIDENCE: The statement of purpose had been updated to reflect the changes in management arrangements. The style is concise but meets the expectations of the Care Homes Regulations 2001. The service users guide is made up of several documents which when pulled together would include those items listed in NMS 1, however at the time of the inspection the full group of documents was not presented in the home. The proprietor stated that the terms and conditions agreements were held centrally in the offices of the proprietors. The terms and conditions agreed between the service and service users must be signed off and present in documentation held at the home. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8. Care plans identified strengths, needs and preferences. Care plans contained reference to the individual service user’s health needs. EVIDENCE: The proprietor had introduced new care planning documentation based on the format developed by the Alzheimer’s society. This demonstrated a strong ethos of person centred planning with strengths analysis, risk assessments and key worker commentary on progress achieved in meeting the plan. All of the current eight service users living at the home had been provided with plans, and these gave a valuable insight into how staff should support service users, as well as commencing a build up of records in respect of how successfully they are able to achieve the goals identified. Care plans contained reference to the individual service user’s health needs and how these should be supported. Additionally there were formats designed to chart health needs and professional visits were present in the plans, which staff should utilise to monitor these needs. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Care plans contained evidence of service users’ preferences in activities. EVIDENCE: This standard was not fully assessed at this visit, however the inspector noted that the care plans for each service user gave indication of their preferences in activities and interests and monitoring sheets to detail how these were met. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home has a complaints policy. EVIDENCE: The complaints policy is in place and the proprietor reported that there had not been any complaints made. Discussion took place with the proprietor in response to the issue of acceptance of gifts reported at the previous inspection. The proprietor felt that the anonymity of the report made it impossible to deal with the situation in any more direct manner than the action taken, and that the unsubstantiated nature of the allegation did not require a POVA alert to be made. The inspector directed the proprietor to consider the service’s policy in respect of protection of vulnerable adults and the stated procedures this set out. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 25. The premises are undergoing refurbishment. Hot pipes and radiators continue to require steps to reduce the risk. EVIDENCE: The maintenance work identified at the previous inspection had been attended to. The premises were undergoing further refurbishment to the communal areas. This included the provision of French windows to the front of the ground floor lounge and redecoration of the room. The proprietor indicated that new furnishings were also planned for this area. Additionally the décor in some service users’ rooms were being updated. This pleased one service user in particular who informed the inspector how much pleasure their room gave them. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 13 The inspector discussed with the proprietor the provision of guarded radiators in the home. The proprietor had considered that the thermostatic valves introduced to all the radiators in the home previously had responded to this requirement, however the inspector informed them of the specific section of the NMS which highlights this issue. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. The staff group are not trained to NVQ level 2. The recruitment processes were not robust. Staff did not have updated training. EVIDENCE: Whilst some staff working at the home had undertaken their NVQ training to a minimum of Level 2, their numbers did not reach 50 of the total staff group. This standard of training is integral to the development of a quality service provision, and the registered person must develop a strategy for attaining this level of qualified staff. The documents for three newly recruited staff were considered at the inspection in order to understand the service’s procedures in recruitment and induction of staff to the home. These records evidenced significant omissions and detrimental practice to the robust and risk assessed process of safe recruitment of staff working with vulnerable adults. Issues such as the acceptance of incomplete applications, lack of evidence in respect of gaps in employment history, evidence of staff commencing employment without application and late application for CRB and POVA statements. The proprietor stated that the evidence held on staff files was not reflective of the actual practice carried out in recruitment of staff, and felt the service adequately upheld its responsibilities in protecting service users. However the Care Homes Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 15 Regulations 2001 19, Schedule 2 require that the documentation listed are held and that the recruitment of staff demonstrates their fitness to work in the service. The staff-training audit indicated that there was significant omissions or failures to provide sufficient training specifically to update basic mandatory training. This included medication, moving and handling, first aid, food hygiene, fire safety, etc. Some staff had never received training in these areas and others were two years out of date. The proprietor stated that this shortfall had been noted and a planned intense training package was set for four days in May and June 2006. Further training developments are also required in issues arising from the assessed needs of service users and staff supervision. The proprietor was directed to develop a training programme for each staff member for the coming year. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38. The home does not operate a quality assurance system. The financial management of service users’ monies is appropriate. The staff group did not receive regular formal supervision. The health and safety documents were in order. EVIDENCE: The proprietor confirmed that a fully operational quality assurance system was not carried out in the home. However, they did point out the daily collection of service users’ feedback in relation to meals and the quality of preparation, which has been in operation for some time. They also stated that informal consultation with relatives took place regularly. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 17 The staff records did not include evidence of formal supervision, although the deputy manager and proprietor had both attended supervision training in October 2006. Staff records indicated that an induction had been carried out with all new staff, however the large number of items signed off on the same date did not support a process that developed and consolidated staff competency. The records relating to the management of service users’ personal allowances were considered. These demonstrated a reasonably robust system for accounting for income and expenditure. Each service users’ monies were held separately with individual account records. A minor issue relating to the numbering of receipts to ensure a more efficient audit trail is presented was the only recommendation arising form this. Records relating to health and safety maintenance of equipment in the home were examined during the inspection. These included the certificates for gas and electrical safety. Lift and moving and handling equipment safety inspections, legionella certificates and Portable appliance testing. These were all satisfactory. The documents relating to the maintenance of fire safety equipment and fire safety procedures were also considered. The routine checks were appropriate and in accordance with fire safety guidance, however the records in respect of staff participation in training and drills was not updated and the proprietor was directed to seek advice from the fire safety officer in respect of these requirements under legislation. Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 1 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 2 X STAFFING Standard No Score 27 X 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 1 X 3 Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 19 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 OP2 Regulation 17(1)(a) Schedule 3 Requirement The registered person must ensure that each service user has a written contract/terms and conditions with the home. Timescale for action 31/05/06 2. OP4 14 This is a repeat requirement. The registered person must 30/06/06 ensure that they can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. This standard was not assessed at this visit and is therefore carried over to the next inspection. The registered person must ensure that the home is conducted so as to maximise service users’ capacity to exercise autonomy and choice. This standard was not assessed at this visit and is therefore carried over to the next inspection. 3. OP14 12 31/05/06 Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 20 4. OP18 13(6) The registered person must ensure that reporting of abusive practice is responded to in accordance with the home’s POVA policy and the local POVA guidelines. This is a repeat requirement. The registered person must ensure that facilities are suitable to meet the assessed needs of all service users, including communication and signage, which assists service users with dementia. This standard was not assessed at this visit and is therefore carried over to the next inspection. The registered person must ensure that pipework and radiators are guarded or have guaranteed low temperature surfaces. This is a repeat requirement. The registered person must ensure that the number and skill mix of staff meets service users’ needs. This standard was not assessed at this visit and is therefore carried over to the next inspection. The registered person must ensure that the staff group are suitably qualified to a minimum expectation of NVQ level 2 or equivalent. The registered person must ensure that the recruitment procedures are robust and protect service users. 30/06/06 5. OP22 23 30/06/06 6. OP25 23,13 30/06/06 7. OP27 18 30/06/06 8. OP28 18 (a) 30/06/06 9. OP29 19, Schedule 2 30/06/06 Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 21 10. OP30 18,19 The registered person must ensure that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims and objectives of the home and meet the changing needs of service users, with particular regard to meeting the needs of service users with dementia. This is a repeat requirement. The registered person must ensure that the home has a registered manager who is qualified, competent and experienced to run a home. 31/05/06 11. OP31OP32 8,9 31/05/06 12. OP33 24 This is a repeat requirement. The registered person must 30/06/06 consider the introduction of quality assurance and monitoring systems to ensure the home is running in the best interests of the service users. This is a repeat requirement. The registered person must provide a business and financial plan for the establishment, open to inspection and reviewed annually. This standard was not assessed at this visit and is therefore carried over to the next inspection. The registered person must ensure staff receive appropriate induction, supervision and training. This is a repeat requirement. 31/05/06 13. OP34 7 14. OP36 18 30/06/06 Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 22 15. OP37 17 16. OP38 12,13 The registered person must revise and update records as detailed in Care Homes Regulations, Regulation 17 and Schedule 4. The registered person must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. This standard was not assessed at this inspection and therefore is carried over to the next visit. 30/06/06 31/03/06 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 OP16 OP17 OP20 Good Practice Recommendations The registered person should ensure that a complaints log is maintained of all complaints received by the home, including informal complaints. The registered person should maintain a record of service users’ choices to exercise their right to participate in the civic process and how this is supported. The registered person should consider whether the dining room facilities are suitable for the purpose of achieving the aims and objectives set out in the statement of purpose and the needs of service users. The registered person should ensure that the documents representing the service users guide are collected together and made available to service users. The registered person should ensure that activities provided in the home are reflective of individual service users’ assessed needs and abilities. 4. 5. OP1 OP12 Anchor Lodge DS0000036541.V286030.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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