Inspection on 22/05/08 for Anchorage Nursing Home

This inspection was carried out on 22nd May 2008.

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

Anchorage Nursing Home 14/05/09

Anchorage Nursing Home 31/05/07

Anchorage Nursing Home 26/09/06

Anchorage Nursing Home 18/03/06

Anchorage Nursing Home 29/11/04

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

CARE HOMES FOR OLDER PEOPLE Anchorage Nursing Home 17 Queens Road Hoylake Wirral CH47 2AQ Lead Inspector Joan Adam Key Unannounced Inspection 22nd May 2008 10:00 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 Anchorage Nursing Home DS0000065659.V362196.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. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anchorage Nursing Home Address 17 Queens Road Hoylake Wirral CH47 2AQ 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) 0151 638 4391 0151 632 0367 aynsleynursinghome@hotmail.co.uk Rolfields Limited Helen Davaney Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2007 Brief Description of the Service: The Anchorage Nursing Home is a three storey building situated in Hoylake. The home is registered to provide nursing care for up to thirty-five service users over the age of 65 years of age. There are bedrooms on all three floors of the home. There are two dining rooms, lounge and conservatory situated on the ground floor, as is the kitchen and laundry room. There is a passenger lift to all floors and a stair/chair lift from ground to first floor. There are two car parks, providing ample space for visitors. Rolfields Ltd owns the home and the registered manager is Helen Devaney. The home have a sister home located in the local area. It costs £480.00 per week to live at the home Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is one star. This means that the people who use the service experience adequate quality outcomes. This unannounced visit took place on 22nd May 2008 by two inspectors and lasted nearly seven hours. The visits were just one part of the inspection. Other information received about the home was also looked at. The home was not informed of the date the visit was to take place, but a few weeks before the visit an acting manager was asked to complete a questionnaire to provide the inspector with some information about the service. The acting manager was also asked to distribute CSCI questionnaires to residents, relatives and health and social care professionals to help the inspector find out what they think of the home. Responses were received from nine relatives two professionals who visit the home and one staff member. These were positive about the care in the home and the staff who work there. During the visit the inspector spoke with the manager, staff, residents and visitors. She toured the premises and looked at various records held by the home. What the service does well: People who live in the home and visitors think highly of staff who work there. Comments such as “ my relative is well looked after” Good homely atmosphere” ”home from home” ”all staff are caring” were received by the inspector. A senior staff member visits people wherever possible to carry out an assessment of their care needs before they move into the home to make sure their needs can be met there. People say that the standard of catering is generally good so they have a good diet. There is a complaints procedure for the home so that people know they are being listened to and that their concerns will be taken seriously and acted upon. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care plans for each person who lives at the home must cover all their identified care needs and describe the actions to be taken by staff to meet those needs. Reviews that take place should be more meaningful to assist staff in the care and to identify any changes to that care. The management of medicines must be improved so that people living at the home are not put at risk through poor practice. The administration of medicines should be improved so that pots or spoons are used when giving tablets to residents and a drink should be offered to help the medicines to be swallowed. All people working at the home should receive regular training in fire safety and take part in fire drills so they know what to do if there is an emergency. All staff involved in moving and handling should undertake training in this subject so that they are able to move people safely. All staff working at the home should receive safeguarding adults training so that they know how to recognise and report any abusive incidents. The environment and furnishings should continue to improve to enable residents to live in a comfortable environment. Toilet and bathroom doors should be clearly labelled so that residents are able to find them easily. Toilet and bathroom doors should be fitted with over-ridable locks to ensure the privacy and dignity of residents is maintained. Action taken following any falls should be recorded and risk assessments put in place. The fire door on the third floor should be added to the alarm system and a risk assessment put in place to maintain the safety of the residents. The personal items of residents living in double rooms, such as soap, toothbrushes and false teeth should be clearly labelled so that staff are aware Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 7 who these items belong to so that the residents dignity is maintained and cross infection is prevented. 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. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 8 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 Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 9 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): 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment of people’s needs is carried out before they move into the home to make sure their needs can be met there. EVIDENCE: The admission details of two residents were looked at. The documentation was completed and contained adequate information so that staff were sure the needs of the resident could be met before they were admitted to the home. The content of the assessment documentation was limited, however the home has new documentation which will improve this. Care plans were based on information obtained at the assessment. The home does not provide intermediate care so standard 6 was not assessed. Anchorage Nursing Home DS0000065659.V362196.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans lack detail so that the care needs of people are not sufficiently detailed and people may not be receiving the care they need. Medication management need to improve so that people who live in the home receive medication at the right time. Some practice issues need to improve so that the residents dignity is maintained. EVIDENCE: All of the people living in the home had a care plan which was written in every day. The home has new care planning documents but have not as yet commenced using these. Care plans were looked at for two people who live at the home. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 11 Care plans were in place in place for a number of needs and these were dated 21st August 2006 shortly following admission to the home. One plan such as “mood affect behaviour ” stated that that the resident “appears apprehensive and withdrawn” had been evaluated monthly since that date and comments such as “ remains bright in mood” were made. This plan appeared to be no longer needed. A plan for communication problems had very little written on the evaluation each month and it appeared that the resident did not have a problem with communication therefore it was questioned if this plan was needed. A plan for a pressure sore was in place and the wound chart had been well completed, the care plan had been reviewed monthly but the reviews were poor and repetitive with comments such as “as before” “continue as before” written. These did not contain adequate information as to the progress of the wound and whether it was responding to treatment and reducing in size or was deteriorating. A visit by the tissue viability nurse had been made on 19th May 2008 but this information was in the daily records. The care plan had not been up dated to highlight the changing needs of the resident. The evaluation records for this resident were poor with no meaningful comments written. A care plan in place for a “sticky eye” written on 10th February 2008 was still in place and was being reviewed monthly. It did not state which eye was sticky or what treatment had been given. This was a short term problem and needed reviewing and up dating as the infection progressed. On speaking to the manager she said this problem had reoccurred but the care plan did not indicate this. The resident had lost weight since being admitted to the home but had not been referred to a dietician. They had been unable to be weighed for some months as they were being nursing bed and an alternative method of assessing weight loss should be used. It was discussed with the manager that care plans should be completely rewritten on a twelve monthly basis as the records looked at did not fully reflect changes in the residents needs and could be more detailed so as to guide staff as to the support needed. The second resident’s care plans were looked at. The moving and handling assessment had been completed and records “ two staff to for everything “ but very little else. On 15th May 2008 it states that two nurses to transfer Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 12 mobile and wheelchair. There is no indication that a walking aid had been offered or if the resident had been assessed for a wheelchair. This resident had a history of falls and accident forms were completed following each fall, however, there was no indication of what action the home was taking to reduce the risk or prevent these falls from occurring. The resident had bed rails, however, most of the falls were occurring at night with comments such as “ found on the floor at the bottom of the bed” This indicated that the resident had climbed down the bed and through the bed rails. The resident had not had a falls risk assessment completed and a bedrail assessment was not in place. It was discussed with the manager as to whether this resident needed bedrails and was more at risk because they were in place. Discussion regarding a pressure mat or alternative means of monitoring the resident could be used. The resident had incontinence problems but it did not appear that these had been addressed adequately. The reviews on these care plans were poor and did not fully reflect changes in the residents needs and could be more detailed so as to guide staff as to the support needed. Medication management was looked at. The storage room for medication was small and shabby. The room was warm but the temperature was taken on a regular basis and was satisfactory. Medicine administration sheets were completed and the recording of medications received in to the home was satisfactory. Adcal tablets which had been prescribed for mornings and evenings were not being given out to some residents at 6pm. This was discussed with the manager as the medication had been prescribed and should be given or a discussion with the GP regarding changes in the prescription need to be made. The manager stated that some residents refused this at teatime. At least five residents were not getting this medication at the prescribed time. The inspector observed a nurse administering medicines and she was seen to put tablets in the mouths of residents with her fingers, she did not wash her hands during the drug round and this can cause cross infection, a drink was offered if the resident was unable to swallow the tablets but not as a matter of routine. She was heard to ask a resident “ do you need something for your bowels” loudly in the main dining room where all residents were having lunch. These actions are not good practice and do not maintain dignity and choice. The inspector discussed these issues with the manager on the day of the site visit. Anchorage Nursing Home DS0000065659.V362196.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a range of activities for people living in the home to take part in so they can keep active and stimulated. EVIDENCE: The home employs two activity co-ordinators and a full programme was in place. Activities such as bingo, quizzes, board games and one to one activities with residents unable to participate such as reading of magazines and books, hand massages. The home produces a quarterly newsletter and all birthdays are celebrated. The home has recently celebrated a golden wedding anniversary for a resident and their family. One resident has a greenhouse and they have grown sunflowers, tomatoes, strawberries and green beans. One resident who is unable to communicate or participate in activities with others goes out with the activities co-ordinator to the local park to feed the ducks. Clothing parties are held so that any resident can choose and purchase their own clothes. Weekly religious services are held for all denominations to Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 14 attend and the Hoylake Chapel come in to home on a regular basis. Activities attended are recorded in the care plan. There were a number of visitors in the home on the day of the site visit. Menus are in place in the kitchen but are not displayed in the dining room. The home does not provide a choice of hot lunch but alternatives are written on a large blackboard in the main dining room. Fresh fruit and vegetables are available and snacks can be provided throughout the day such as biscuits and sandwiches. During the morning a drink was given to the residents but no one was given a choice of what they wanted to drink. The residents were brought in to dining room but appeared to be sat for quite some time before lunch was served. It appeared that the routines of the home were based on tasks and did not appear to be person centred. During the handover between staff a carer allocated tasks to be completed during the afternoon. Some residents were in their rooms after lunch to have a sleep or to watch TV. Survey forms returned to CSCI from residents and relatives were positive about the home with comments such as “ my relative is looked after really well” “home has good friendly atmosphere” “all staff are caring” received. Anchorage Nursing Home DS0000065659.V362196.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): 16,18, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are procedures in place at the home to ensure that complaints are handled well and action taken to protect people from abuse. However, not all staff have received training about safeguarding adults so may not know what to do if abuse is suspected or found. EVIDENCE: The complaints procedure for Anchorage nursing home is displayed in the entrance to the home. The complaints log showed that the one complaint that had been received by CSCI and sent to the manager of the home to investigate had been dealt with within the appropriate timescales and that actions had been taken to put matters right. The home has a policy in place regarding safeguarding adults. The home has had one issue regarding safeguarding of adults and the manager has dealt with this appropriately. On looking at the training matrix only thirty five out of sixty staff have attended Safeguarding adults training. This was a requirement on the last inspection report from May 2007 and from September 2006. Some further dates for this training have been booked. This requirement has not been met. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A number of improvements need to be made so that people live in more comfortable surroundings. Some furniture needs to be replaced to enable residents to be more comfortable. EVIDENCE: The home has had some areas decorated since the last inspection such as bedrooms as they become vacant with new carpets and furniture replaced. The new furniture has a bedside table with a locked drawer facility to allow residents to have a lockable personal space. A new sluice facility has been fitted and the home has a further sluice, which is waiting to be fitted. A new floor has been laid in the kitchen following a visit by Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 17 the environmental health officer. A new carpet has been laid in the dining room and in some areas of the corridors. The home was clean and odour free on the day of the inspection. There were however, still some areas of the home that require improvement. Some bedrooms have electric heaters as the main central heating boiler is to be replaced. A date is required by CSCI for the commencement of this work. On a tour of the home the inspector opened a fire escape door on the third floor of the building. This gave access to a metal fire escape and did not have any safety or alarm system in place. This is a health and safety risk for the residents living at the home and must be rectified. One bedroom on the top floor had a window frame that was rotting and unsafe. This needs to be replaced. On the middle floor of the home the corridor carpets need to be replaced as they are worn. An inventory of the divan beds throughout the home needs to be made as some of the beds are old and worn and need to be replaced. The home has only two adjustable beds and as some of the residents are frail and need of nursing in bed further adjustable beds must be purchased so that the staff can care for the residents safely. An inventory of the chairs throughout the home needs to be made as some were ripped and worn which is a cross infection hazard. These armchairs were of the plastic type and staff were placing sheepskin rugs over the chairs to make them more comfortable for the residents to sit in. The bathrooms and toilets throughout the home need to be fitted with overridable locks as none of the bathrooms and toilets can be locked to maintain the privacy and dignity of the residents living there. Some bathroom flooring is not fitted properly and can cause a trip hazard. During the site visit it was observed that a bath had been filled by a staff member and left whilst they went to get the resident. The water may have been cold when they returned with the resident and this is a health and safety risk as a resident may have gone in to the bathroom and fallen in to the bath. The toilets and bathrooms throughout the home need to be identified as each door within the corridors are the same and this could cause confusion to the residents who are trying to find a toilet. There were no names on the bedrooms doors and this could cause some residents to be unable to find their own bedroom, as the corridors were similar. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 18 In two of the double bedrooms there were bars of soap on dishes with no identification as to which resident they belonged to. In one double room a set of dentures was in a pot with no name on them, in another double room there was only one toothbrush present which had no name on it. The residents living in these bedrooms need to have personal items identified clearly so that no other person uses these items and to ensure the residents’ dignity is maintained and prevents cross infection. A set of dentures was found in another double bedroom but these were not named and the manager was unaware as to who they belonged to. The carpet outside the laundry area must be replaced as it is ripped, worn and stained. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff training needs to be improved so they can maintain and develop their skills when providing care. Recruitment procedures are thorough to make sure that new staff are suitable to work with the people who live at the home EVIDENCE: Care staff are well regarded by people living in the home and relatives. Comments were made such as, “very good, everyone is very kind.” Duty rotas were looked at and the home has adequate numbers of staff on duty to meet the needs of the residents. The training records for staff was looked at and there were over fifty per cent of care staff who had achieved NVQ level 2 in care. Some staff at the home had not received mandatory training regarding fire safety, health and safety, moving and handling and food hygiene. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 20 Training records indicated that forty four out of sixty staff had attended a fire safety training course in the last year. This means that staff may be unaware of what to do in the event of a fire. The records also indicated that only thirty four of the sixty staff have completed moving and handling training in the previous twelve months. This means that some people living in the home could be at risk of harm or injury through poor lifting practice. Only thirty five out of sixty staff have attended Safeguarding adults training. The manager is addressing this issue by booking training sessions, however, this was a requirement on the last inspection report from May 2007 and from September 2006. These requirements have not been met. Some training by trained staff regarding tissue viability, peg feeds, continence and catheter care have been attended. Two staff members have had training with regard bed rails risk assessments and the manager will also be completing this course. The recruitment records of four staff were checked. All the files looked at contained all relevant information required to enable the management to be aware that the person could work with vulnerable adults. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of management need to improve to ensure the safety of the residents living at the home is maintained. EVIDENCE: The manager is an experienced nurse and has been registered with CSCI. She works sixteen hours supernumerary and has recently employed a deputy manager. Records indicated that the maintenance man tested and checked fire safety equipment. There had been only forty four out of sixty staff members who had undertaken fire safety training since May 2007 so staff might not be clear Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 22 about what they had to do to protect residents and themselves if fire broke out at the home. The records also indicated that thirty four out of sixty staff have completed moving and handling training in the previous twelve months. This means that some people living in the home could be at risk of harm or injury through poor lifting practice. Recruitment files looked at showed that all relevant information required to enable the management to be aware that the person could work with vulnerable adults. A small amount or residents money was being processed via the company’s own bank account, which is a breach of regulation, despite accurate record keeping by the home’s administrator. This was discussed with the administrator and registered manager who assured the inspector that separate accounting facilities will be established as a priority. This was a requirement at the last inspection in May 2007 and has still not been met. It was once again discussed with the manager and administrator who said they would contact the pensions agency and transfer monies in to the residents’ own account. CSCI have requested confirmation by letter when this has been completed. Accident forms are completed following any falls by the residents, however, the section of the form “action taken “ is not completed and the home has no recorded actions of how falls can be prevented or monitored. One resident had sustained six falls within a short time and there was no plan of action or risk assessment in place to alleviate these incidents. All residents should have a risk assessment completed regarding the safe use of bed rails. The fire exit door on the third floor of the home must be risk assessed and alarmed to ensure the safety of the residents living there. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 17 (1)(a) Requirement The registered person must ensure that there is an up to date written plan of care of each resident, to enable their changing needs can be met. Unmet requirement from 26/09/06 and 31/05/07 Care plans must be kept under review to demonstrate that people’s changing care needs have been identified and effective measures taken to meet those changed needs. Unmet requirement from 26/09/06 and 31/05/07 Medicines must be administered safely in accordance with the home’s policy and procedures and the records must be clear and accurate. This means that people living in the home can be confident they will receive their medicines as prescribed. Unmet requirement from 26/09/06 and 31/05/07 All staff must receive to date moving and handling training so people living in the home are not DS0000065659.V362196.R01.S.doc Timescale for action 30/06/08 2 OP7 15 (2)(b, c & d) 30/06/08 3 OP9 13 18/06/08 4 OP38 18(1)(c) 31/07/08 Anchorage Nursing Home Version 5.2 Page 25 5 OP38 23 (4)(d) 6 OP18 13(6) placed at risk of possible injury. Unmet requirement from 26/09/06 and 31/05/07 All staff in the home must undertake an annual refresher course in fire safety training so that people in the home are protected. Unmet requirement from 26/09/06 and 31/05/07 The registered person must ensure that all staff employed receive suitable and sufficient training in the protection of vulnerable adults, including the prevention of abuse. Unmet requirement from 26/09/06 and 31/05/07 The registered person must ensure that residents have a risk assessment in place if they are vulnerable to falls and that action taken following the falls is recorded. The registered person must ensure that all residents have a risk assessment in place as to the need to use bed rails. The registered person must ensure that the central heating system at the home is repaired/replaced and confirmation of when the work has commenced be sent to CSCI The registered person must ensure that the fire escape on the third floor is alarmed to ensure the safety of the residents. 31/07/08 31/07/08 7 OP38 4(c ) 30/06/08 8 OP38 4(c) 30/06/08 9 OP19 23 (2) (p) 30/06/08 10 OP38 4 (c) 16/06/08 11 OP35 20(a) (b) The registered person must 30/06/08 ensure that all residents personal monies is paid in to the residents own bank account. Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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 Anchorage Nursing Home DS0000065659.V362196.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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