Inspection on 16/09/05 for Ancliffe

This inspection was carried out on 16th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ancliffe 27/02/08

Ancliffe 26/06/06

Ancliffe 17/02/06

Ancliffe 30/11/04

Ancliffe 03/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE ANCLIFFE Warrington Road Goose Green Wigan WN3 6QA Lead Inspector Judith Stanley Unannounced 16 September 2005 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 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. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ancliffe Address Warrington Road Goose Green Wigan WN3 6QA 01942 230439 01942 498211 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CLS Care Services Ltd Mrs Kathleen Ryan CRH Care Home 40 Category(ies) of OP Old Age (40) registration, with number PD(E) Physical Disability (8) of places ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 8 PD(E) and up to 40 OP Date of last inspection 30 November 2004 Brief Description of the Service: Ancliffe - part of the CLS group of Homes - is situated on the outskirts of Wigan and is approximately 10 minutes away from the main town centre, other local amenities are close by. Ancliffe provides personal care and support for 40 residents over the age of 65 years. The Home is a purpose built, single storey building, all rooms are single, 4 offer en suite facilities. The Home has several lounge/dining areas, bathrooms and toilets are sufficient in number and are in close proximity to private and communal areas. There is limited outside space, however there is an enclosed patio area that is accessibe to service users. Limited car parking is available at the front and side of the Home. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a 4 -hour period on one day. The first part of the visit was spent talking with the manager and looking at records and information the home holds on the residents (care plans). The remainder of the day was spent speaking at length to 6 residents, 2 visitors, and 4 members of staff as well as making a tour of the premises. Other staff and residents were spoken with during the course of the day. What the service does well: The home had a group of staff who had worked at the home for a long time and residents spoken with liked the staff team. One resident said, “the staff are great, they get on with their jobs and don’t interfere. You can leave private things and money in your room, they are very honest and would touch a thing”. Another resident described staff as “kind” and “caring”. The home provides a wide range of activities and staff work hard to provide an enjoyable and relaxed environment. Staff were observed making time to sit with residents either on their own or in groups. The manager and staff work hard to promote resident’s choice and independence. Residents confirmed that they are involved in decisions about the home e.g. food, activities, and trips out. One resident who has been at the home for some time was due to leave and live independently, he was complementary about the staff saying how much they had helped and encouraged him to carry out some tasks for himself and had helped build his confidence to go and live back in the community. Meals were enjoyed by residents, and residents said the food was very good and plenty of it. Residents plan a day’s menu of their choice once week. Before residents went into the home, the manager visited them either in their own home or in hospital to make sure the care they needed could be provided by the home. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 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. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 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 standard(s) EVIDENCE: None of the key standards were inspected on this occasion. Standard 6 does not apply to Ancliffe as the home does not offer an intermediate care service. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 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 standard(s) 7 & 9 The standard of care planning and review was poor, care plans had not been updated, therefore could not provide staff with the information needed to meet the residents’ needs. In the main the systems for the administration of medication were good, however one area of practice was poor which could potentially place service users at risk. EVIDENCE: CLS has recently introduced new paperwork to be included in the care plans, this should make the care plans easier to read and follow. Three care plans were looked at and none of them had been updated and amended monthly as required, one had not been reviewed since March 05. If there are no changes to the written care plan at the monthly review, the notes should indicate this and be signed and dated. This has been a requirement from previous inspections. There was no evidence to demonstrate that residents or their relatives / representative had been consulted in the drawing up and in the maintaining of information in the care plan. The lack of updated information in ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 10 the care plans could prevent staff from having relevant information to ensure that the needs of the service users are fully met. In general the administration and recording of medication was satisfactory. However, it was noted that one service user had been given several tablets to take after lunch. These were observed to be left on the dining table at the side of the resident to take when ready. This is not good practice as other residents could have easily picked them up. If residents wish to self medicate appropriate systems must be in place. Staff administering medication could not have known if the resident who the tablets had been prescribed for actually took them. This was discussed with the manager to rectify the situation. Staff administering medication have received medication training, however it was not adhered to on this occasion. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 11 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 standard(s) 12 & 15 Social activities and meals were both well managed, providing daily variation and interest for people living at the home. EVIDENCE: The home employs an activities coordinator who, with the help of the residents plans and wide range of activities, which are appropriate to the needs and capacities of the individuals. Residents spoken with said how much they enjoyed the activities; these include bingo, quizzes, board games, jigsaws, videos, afternoon visits to events at the local church and trips out. One resident enjoys going to watch the local rugby team and is accompanied by a member of staff. At the time of the inspection the staff and residents were planning a week of celebration to commemorate 60 years since the ending of World War II. Residents were also observed pursing their own interests, this included knitting squares for blankets and enjoying reading daily papers. The dietary needs of the residents were well catered for with a balanced and varied selection of food available. Comments with regard to food were good and residents spoken with said, “the food was excellent”, and that “there was always a good choice available”. The cook was spoken with and said that the menus were planned from head office, but were subject to change. One day a week residents plan what they would like to eat. The Inspector observed breakfast being served until 10.30 a.m. to allow residents to get up when they ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 12 wish. Residents confirmed that they could have a choice of cereals, fruits, toast and preserves and pots of tea or coffee, a cooked breakfast is available if required including bacon, eggs, tomatoes, black pudding, baked beans etc. A lighter lunch is served; this consisted of asparagus soup, a choice of sandwiches or bacon and tomatoes, followed by yoghurts or fruit and ice cream roll or evaporated milk. Dinner is served late afternoon and residents were being offered a choice of battered or poached cod, chipped potatoes and seasonal vegetables, or pork steaks, a selection of homemade cakes was available for dessert. The cook has worked at the home for some considerable time and knows the resident’s likes and dislikes. The cook confirmed that any special diets would be catered for including, soft or pureed diet and diabetic diets as required. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 13 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 standard(s) 16 & 18 Systems are in place with regard to the investigation of complaints and adult protection issues, ensuring that residents were listened to and protected. EVIDENCE: A complaints procedure was in place, which was displayed in the home. There have been no complaints made to the management of the home since the last inspection and no complaints have been brought to the attention of the CSCI. One relative spoken with said she had no complaints about the care her relative received and if she had any concerns she would discuss it with the manager and was confident that any issues would be dealt with. Policies and procedures on the protection of vulnerable adults were available within the home. The manager confirmed that most staff had now received training in the protection of vulnerable adults and other staff were waiting to complete training. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 14 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 standard(s) 19,24 & 26 The standard of the environment with Ancliffe is good, providing residents with a comfortable and homely place to live. Infection control procedures are good, making this a clean environment for residents. EVIDENCE: From a tour of the building, it was seen that the premises were being maintained to a good standard, both inside and out. A rolling programme of decoration and refurbishment is ongoing. The residents smoking lounge has recently been decorated, however the carpet is badly burned and the room would benefit from this being replaced. The premises were clean and free from any offensive odours throughout. Resident’s bedrooms were seen to be comfortable and well equipped. One resident spoken with said that the bedrooms were small and when she first moved in she felt uncomfortable in such a small space, but now she has got ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 15 use to it and likes her room. It was observed that residents had brought with them personal belongings from their own homes including small items of furniture, photographs and mementoes. The home offers several lounge/dining areas throughout the home, however most residents tend to have a favourite lounge that they like to sit in. Some residents preferred to stay in their own rooms and pursue their own interests. Systems were in place to control the spread of infection. Staff were observed to be knowledgeable about infection control procedures. It was observed that protective aprons and gloves were used for different tasks. The home has suitable laundry facilities and staff confirmed that all equipment was in good working order. Resident’s clothes were observed to be clean, ironed and returned to their rooms. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 Staff morale is good, with a core group of staff that worked at the home for some time. This ensures residents are provided with care by people they know and are familiar with. The practice of retaining two staff on overnight duty needs constant review to ensure residents’ needs are met. Good progress had been made to provide training on a range of subjects and NVQs for staff, to enable them to carry their jobs in a competent manner. Training is lacking in caring for people with dementia to ensure their needs can be met. EVIDENCE: There were several of the staff who had worked at the home for many years, who were providing the residents with consistent care. There were an adequate number of staff on duty during the day and early evening. The manager confirmed that two waking staff are on duty for up to forty residents. If extra night staff were required due to a resident being ill additional staff would be brought on duty to assist. It was evident that staff training is progressing well with the majority of staff having completed NVQ level II in care; other staff have enrolled on NVQ and are waiting a start date. Although the home is not registered to offer dementia care, it was evident from observations that several residents, although they had not had a clinical diagnosis of dementia had varying degrees of confusion. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 17 All staff at the home must be aware of the signs and symptoms of this and be suitably trained to offer the appropriate care required. . ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 38 The home is managed to a satisfactory standard, which results in a consistent and reliable service for the people using it. All staff had received relevant health and safety training to ensure their safety and the residents safety was protected. EVIDENCE: The manager has a good understanding of the needs of the residents in her care; she is a “hands on” manager and obviously enjoys being with the residents. It was noted that the manager related well with residents in a friendly and respectful manner. The manager is still working to achieve the NVQ level 4 in management and confirmed this should be completed by the end of this year. Health and safety issues were satisfactory with regular maintenance checks of equipment being undertaken. All accidents and incidents were being correctly ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 19 recorded and reported. It was evident from checking files and from discussion with the manager and staff that all staff had received mandatory health and safety training. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation OP14 &15 Requirement Timescale for action 30/11/05 2. OP9 Sch 3 & 13 The manager must ensure that all care plans are fully completed with all the necessary information required. The care plans must be reveiwed on a monthly basis or more frequently if required. The manager must ensure that 31/10/05 staff administering medication adhere to the homes policy on medication. Staff must ensure that residents have taken medication when its given out and suitably recorded. 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 OP27 OP30 Good Practice Recommendations The carpet in the smoking lounge is need of replacing, it is burned in several places and looks unsightly. Additional night staff should continue to be provided if the dependency levels of residents changes. All staff would benefit from training in dementai care, to ensure that residents who are confused are being cared for by suitably trained staff. F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 22 ANCLIFFE 4. OP31 The manager should continue to work to achieve the NVQ level 4 in management by the end of 2005. ANCLIFFE F56 F06 S5721 Ancliffe V232214 Stage 4 160905.doc Version 1.30 Page 23 Commission for Social Care Inspection Turton Suite, Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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