CARE HOMES FOR OLDER PEOPLE
Ancliffe Warrington Road Goose Green Wigan Greater Manchester WN3 6QA Lead Inspector
Judith Stanley Unannounced Inspection 17th February 2006 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 Ancliffe DS0000005721.V268743.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. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ancliffe Address Warrington Road Goose Green Wigan Greater Manchester WN3 6QA 01942 230439 01942 498211 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) www.clsgroup.org.uk CLS Care Services Limited Mrs Kathleen Ryan Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age (8) of places Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 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 16 September 2005 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 accessible to service users. Limited car parking is available at the front and side of the Home. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over a 3 - ½ period on one and was unannounced. The manager was available to assist with the inspection. Part of the time was spent in the office looking at records the home holds on residents (care plans) and other documents that the home needs to keep to run its business, and part of the time was spent in conversation with residents, staff and visitor. What the service does well: What has improved since the last inspection?
The home is continually working to improve the service and facilities for residents and their visitors to enjoy at the home. Since the last inspection the programme of redecoration has continued, maintaining a good standard of comfort and cleanliness throughout. A new floor has been put down in the resident’s designated smoking lounge. The care plans looked at had been reviewed by staff monthly as required; this was seen to be occasionally overlooked at the last inspection. Ancliffe DS0000005721.V268743.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. Ancliffe DS0000005721.V268743.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 Ancliffe DS0000005721.V268743.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): 3. Standard 6 does not apply at Ancliffe as the home does not offer an intermediate care service. The admission procedure ensures that all people receive a proper assessment prior to moving into the home in order to ensure that their care needs have been fully identified/assessed and that the home is capable of meeting those identified needs. EVIDENCE: The manager visits prospective residents prior to them moving in to home. This assessment of their needs is carried out at a place most suited to the person, either at their own home, hospital or at Ancliffe. The assessment procedure is sufficiently detailed to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. Ancliffe DS0000005721.V268743.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, 8 and 10 The standard of care planning and review had improved; care plans had been updated as required and provided staff with the information needed to meet the resident’s needs. The health and personal care needs of residents are well met, with evidence of multi disciplinary working taking place on a regular basis. Residents could be confident that they would be treated with respect, and that their to privacy and dignity would be promoted. EVIDENCE: Individual care plans were made available for inspection and examination of a number indicated that all resident’s health, personal and social care needs are planned for. Three individual care plans examined were found to be up to date and had been reviewed monthly as required. Relatives spoken with were aware of the care plans and new they could access them if required.
Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 10 There was evidence of access to community services such as the residents GP, chiropody, District Nurse support, advice and ongoing treatment and access to aids and adaptations that maintain the quality of life for residents. Staff have a good awareness of how to protect resident’s dignity and privacy. They were seen to knock on resident’s bedroom doors and bathrooms and wait for a response before entering. They were seen to deal with residents in a supportive manner, for example doing things with them and not for them when appropriate. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 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 the following standard(s): 13 and 14 The routines of daily living are flexible enough so that the different needs, expectations and preferences of residents are met. Residents are assisted to maintain contact with friends and family. Residents are kept informed and are helped to maintain a good level of independence, and to exercise choice and control their lives. EVIDENCE: It was clear from observations, from records, and from conversations with residents that they are offered real choices about their lives. The manager encourages residents to maintain contact with family and friends and one resident regular goes to local rugby matches with the manager and her family. One resident, who is still very fit goes out of the home most days, shopping and for walks. On some afternoons, some residents attend activities at the local church Residents spoke well about being able to maintain a good level of independence. Residents said they had been able to bring some of their possessions, sufficient to make their bedrooms feel more personal. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 12 The home is well supported by relatives. Relatives spoken with were complementary about staff and said they were always made to feel welcome whenever they visited. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: This section was not assessed on this occasion. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: This standard was not assessed on this occasion. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 15 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): 29 Staff were subject to an appropriate recruitment process that provides the necessary safeguards to protect residents living at the home. EVIDENCE: Random inspection of two staff personnel files showed revealed these contained an application form, two written references, proof of identification for example passport and driving licence. No staff are employed without a Criminal Records Bureau check. Ancliffe DS0000005721.V268743.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): 35 and 36 A satisfactory accounting system is in place, which protects resident’s interests. Staff are supervised to ensure that they carry out their jobs appropriately. EVIDENCE: The home administers a number of personal allowances of which an income/expenditure sheet with a running total is maintained for each resident. Monies are kept separate and securely stored. Random checking of some resident’ s finances showed that money and balance sheets were correct. Staff supervision is ongoing and staff are now receiving regular supervision sessions as required.
Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 17 Ancliffe DS0000005721.V268743.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x 3 3 x x Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard OP27 OP30 OP31 Good Practice Recommendations Additional night staff should continue to be provided if the dependency levels of resident’s change. All staff would benefit from training in dementia care, to ensure that residents who are confused are being cared for by suitably trained staff. The manager should continue to work to achieve the NVQ level 4 in management by June 2006. Ancliffe DS0000005721.V268743.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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
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