Inspection on 26/06/06 for Ancliffe

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 17/02/06

Ancliffe 16/09/05

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 Greater Manchester WN3 6QA Lead Inspector Judith Stanley Unannounced Inspection 26th June 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.V294573.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. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 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.V294573.R01.S.doc Version 5.2 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 17th February 2006 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. The current scale of fees ranges from £312,15 to £354,04. Additional charges are made for hairdressing, toiletries, newspapers and magazines, transport, private chiropody. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a 5- hour period on one day and was unannounced and included a site visit. The homes manager was available to assist with the inspection. The first part of the day was spent looking at some of the records the home keeps on residents (care plans), staff files and a selection of health and safety certificates. The rest of the time was spent talking with residents and staff and visitors calling at the home. A full tour of the premises was also made. Prior to the inspection, comment cards were offered to service users/relatives and health care professionals for example GPs and District Nurse Teams. One relative comment card was returned confirming overall satisfaction with the home and the services provided. A healthcare profession has said that the home communicates clearly and works with them, that they see their clients in private and staff have a clear understanding of the care needs of the service users. Another health professional has no concerns regarding the care provided, however states, “It would be beneficial to health professionals to have a treatment room for required intervention”. Ten service users have returned comment cards and positive responses given, for example, “ I am very happy with the home”, another states,“ I’m happy with everything that happens and the way they care for me, I like the activities and when the artists come in to sing”. Another resident states, “if I wasn’t happy with something, I would tell any of the care staff, they’re always happy to help. What the service does well: The home has a group of staff who have worked at the home for several years; this helps provide residents with reliable and consistent care. The home has a very friendly atmosphere, which is evident when you enter the building. Visitors spoken with said, “ staff are very friendly, they always make you welcome whenever you visit”. One visitor said that her relative was very poorly and that the manager and staff have kept them informed at all times and the care they have provided has been “brilliant”. The home has a good activities coordinator that provides a wide range of activities and outings suited to the capabilities of the residents. The home provides a good choice of meals that offer a well- balanced and nutritious diet for the residents. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The daily progress sheets in the care plans must be completed at least twice a day, every day. It was noted that dates did not follow on in order and gaps were seen. All care plans need to contain a social history about resident’s work and family life, past experiences, likes dislikes, interests and hobbies. This helps to provide care staff with background information and helps them to understand the residents they are caring for a little more. The manager must maintain an up to date record of all staff training, copies of certificates, and when refresher courses are due. The manager must devise and maintain a suitable filing system. Any information relating to staff must be kept in the person’s own file, for example proof of identification that accompanies an application for a post working at the home. All staff must be suitably trained in the Protection of Vulnerable Adults, currently staff work through the company policy. This training needs to be more in depth to ensure the safety of the residents living at the home. All staff must receive regular supervision, at least 6 times a year as part of the normal management process. The lounge carpet in the middle lounge is heavily stained and must be replaced. The lounge has had new furniture and the carpet spoils the overall effect for residents. The patio areas require attention; weeds are overgrown which spoils the area for residents to use. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 7 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.V294573.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 Ancliffe DS0000005721.V294573.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 does not apply at Ancliffe. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory pre admission assessment procedure to ensure the home can meet the assessed needs of the residents. EVIDENCE: Four care plans were inspected, including the most recent admission in to the home. A pre-admission assessment had been completed prior to admission and was available on all files looked at. Assessments are carried out at the most convenient place for the prospective resident, either at their own home or in hospital. The assessment ensures that the home and staff can fully meet the needs of the prospective resident. The assessment document was detailed and covers the necessary areas, including personal care and physical well being; type of diet and weight, sight, hearing and communication, mobility and medication and history of falls. If a resident has been in hospital the manager goes out to reassess to ensure the resident is ready and able to return to the home. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 10 Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 11 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): 7,8,9 &10 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. In the main, the care plans were detailed and reflected the care needed, however not all had been updated as required; this could result in some aspects of care being overlooked. The health needs of the residents are well met with evidence of good multidisciplinary working taking place on a regular basis. The systems for the administration of medication are good, with clear arrangements being in place to ensure resident’s medication needs are met. Personal support is offered in such a way as to promote residents’ privacy, dignity and independence. EVIDENCE: Progress had been made on the development of care plans. How the care plans are completed depends on the member of staff whose responsibility is to Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 12 keep them up to date. Ultimately it is the managers’ role to oversee and check the care plans on a regular basis. As previously stated the homes pre admission assessments were in place and the rest of the care plan is built up from the initial assessment. Not all the care plans had been agreed and signed by the resident or their relative. In two of the care plans, the daily progress sheets had gaps on them where they had not been completed; the manager could offer no explanation as to why staff had not filled them in, apart from the fact there were no changes or issues of concern. Care plans are lacking a personal profile; those seen were very brief and did not provide clear information about the residents past life and work experiences, hobbies and interests, where people used to like to go out to and holidays they enjoyed. A good background history helps staff know more about the person they are caring for and provides topics for initiating conversation. Detailed risk assessments were in place in each of the files inspected. They covered areas such as nutrition, pressure areas, moving and handling and falls. Other risk areas were identified in connection with daily living activities and it was evident that responsible risk taking was regarded as part of the normal expression of peoples’ independence by the staff team, for example one resident goes out on his own nearly everyday and has recently returned from a holiday alone in North Wales. The health care needs of the residents were being well met with evidence of good multi disciplinary working taking place on a regular basis. Feedback from two health care professionals was positive and they expressed overall satisfaction about the care the residents receive. One additional comment made regarding the lack a treatment room, this would be beneficial for seeing residents in and providing any treatment required, this is currently carried out in the resident’s own room. The arrangements for resident’s medicines were secure and appropriately documented. One resident self medicates and has her medication in a locked drawer in her room. Staff record the medication taken and reorder for the resident as required. A member of staff was observed administering medication, this was given in an appropriate manner and immediately recorded on the individual’s drug sheet. The home does hold a small amount of controlled drugs. The controlled drugs and the controlled drugs register were checked and no discrepancies noted. The member of staff administering medication confirmed that she had undertaken training in administering medication. Residents spoken with said that staff respected their privacy and dignity, and relatives spoken with also expressed satisfaction in this area. Throughout the inspection, staff were observed interacting with residents in a natural and respectful way. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 13 Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 14 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): Outcome in this area is good. This judgement was made using available evidence including a visit to the service. The home provides a wide range of activities that takes account of individual expectations and preferences, and provides good opportunities for social inclusion. Residents maintain good links with family and the local community as they choose. Residents are able to exercise as much personal freedom and choice as possible with a risk assessed framework. The meals in this home are good offering choice and variety, and catering for special dietary needs. EVIDENCE: The home has a very good activities coordinator who with the help of residents plans a full range of indoor activities and trips out of the home. The activities coordinator is very enthusiastic about her work and is a flexible worker who often changes her times of being in the home to suit the residents, this Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 15 includes coming in of an evening or at weekend. On one week the outings include visits to a Brass Band concert, going to watch a show organised by the Leigh Miners Association, a visit to the Monaco dance hall and excursion out to Ormskirk. Residents are asked if they wish to partake and it is their choice to go on which outing they like. The activity coordinator confirmed that residents could go on them all if they wanted. Other activities are planned in the home; these include bingo, arts and crafts, board games and puzzles, gentle exercise, visits from entertainers, a few residents enjoy playing scrabble and have formed a scrabble club. On the day of the inspection, it was the film club afternoon and residents get together in one lounge and enjoy a movie of their choice, the pick of the day was the Glen Miller Story, one resident has poor eye sight and could not watch the film but said she comes along as she enjoys the music. The activities coordinator maintains a file of all the activities planned and if they were successful and who likes to join in and who prefers to be alone and whom she needs to spend time just chatting with. One resident enjoys gardening and has been provided with flowers to redo the tubs and pots of the patio. There are no restrictions on visiting times and visitors confirmed they are always made welcome. Two visitors spoken with said that the all the care staff were good, they are always friendly and helpful and nothing is too much trouble. There are several areas where residents can entertain visitors, in any of the lounges or the small dining room where there is access to kitchen facilities or in the privacy of their own room. Staff encourage residents to maintain contact with family and friends and staff confirmed that there is good family support. A social event takes place weekly at the local church and several residents attend. One resident goes out every day for a walk or to the local shops and has recently had a holiday on his own in Llandudno of which he told the Inspector how much he had enjoyed himself. The manager accompanies one resident to home games of the local rugby team, the resident told the Inspector about the games and that he looks forward to going and how he has a good time. Residents confirmed they get up when they want to and go to bed when they are ready. One resident said, ”they don’t push you off to bed, there’s no rush”. The meals served at the home are good and offer variety and choice. Menus were available for inspection. Breakfast was observed and is served on a flexible basis to allow residents to get up when they are ready. There is a good choice of breakfast dishes offered, grapefruit, cereals, full English breakfast, toast and preserves and pots of tea or coffee. A lighter lunch is served; residents were offered a choice of soup, assorted sandwiches, bacon and tomatoes, plaice and peas, followed by choc-ices or rice pudding. The main meal of the day is served late afternoon and consisted of cheese lattice pie or salmon fish cakes or corned beef hash with boiled potatoes and carrots and cauliflower, followed by home made cakes or scones. Hot and cold drinks Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 16 and snacks are available during the day and supper and a choice of drink is served before residents retire. One residents spoken with said, “the food is always very good, there‘s plenty of it and you can have want you want”. There are several dining areas and most residents dine in the dining rooms, however residents could dine in the privacy of their own room if they wished. The dining tables were seen to be nicely set with matching crockery and suitable cutlery. In the middle lounge/dining area it was noted that new chairs had been purchased and looked very nice, the heavily stained carpet spoils the overall effect. The carpet needs to be replaced as it is passed cleaning. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents and their supporters can be assured that their complaints and concerns will be listened to and appropriate action taken. The home has a adult protection policy, however not all staff have completed training in this area which could potentially place residents at risk. EVIDENCE: There have been no complaints made to the manager of the home since the last inspection and no complaints have been brought to the attention of the CSCI. Staff spoken with were clear about their obligation in protecting residents from abuse in any of its forms and knew about whistle blowing. Up to date policies and procedures are available at the home and the manager confirmed that she had worked through this with staff, however there was nothing to confirm this. Some staff have completed NVQ level 2 which covers Adult Abuse in one of the modules. All staff must receive in depth training in the Protection of Vulnerable Adults, in order to be aware of the procedures that apply to protect residents. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to the service. Some areas of the home require more attention to provide residents with a more comfortable homely and pleasant place to live. Infection control procedures are good, making this a clean environment for residents. EVIDENCE: From a tour of the premises, it was evident that some bedrooms had been decorated and the some new furniture had been purchased for the middle lounge. The carpet in the middle lounge needs to be replaced as this is heavily stained and it passed cleaning. With a new carpet and the new furniture already there it would make the lounge a more pleasant area for residents to sit in. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 19 There is limited garden/patio space, so what area there is should be kept neat and tidy for residents to sit out in. As previously stated one resident has worked hard in planting summer plants in the various tubs and pots, which look very attractive. These would be better offset if the patio area was weeded and kept tidy. Systems were in place to control the spread of infection. Staff were seen wearing protective gloves and aprons for different tasks. The laundry is sited away from food preparation and food storage areas and does not intrude on the residents. Residents were seen to be clean and nicely groomed with their clothes nicely washed and ironed. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staffing levels were satisfactory during the day. Numbers of night staff on duty need to be kept under review to ensure that the residents care needs continue to be met. Not all staff have not received all the necessary training to ensure that residents are safeguarded and protected. In the main the standard of recruitment practices were good ensuring the safety and protection of residents living at the home. EVIDENCE: On the day of the inspection there was an adequate number of staff on duty. The number of night staff on duty must be constantly reviewed to ensure that the resident’s needs are fully met. There are normally two waking night staff on, however the manager could demonstrate where, on occasion a third member of staff is brought on duty, for example if a resident was ill. Staff training for NVQ is progressing well with over 50 of staff having completed NVQ level 2. Information obtained prior to the inspection from the manager states that 12 member of staff hold a current first aid certificate and 11 staff are responsible for administering medication. Further training is Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 21 planned (no dates submitted) in Moving and Handling, Fire Training, Pressure Area, Continence and Abuse Training. Staff spoken with confirmed what training they had undertaken, however staff files did not contain evidence to confirm this. The manager must produce a training matrix to show what training staff have undertaken, on what date and when refresher dates are due, this is to be forwarded to the CSCI. Copies of any training certificates must be kept on file. Three staff files were inspected and the recruitment procedures checked. The company has robust procedures in place for the recruitment and selection of staff. On checking staff files staff had completed an application form, two written references were on file, and evidence on two files of Criminal Records Bureau checks (CRB), the third file had no evidence of a CRB, however the manager contacted the CRB during the inspection and they confirmed the date of the CRB. The manager spoke to the member of staff by telephone who confirmed she had a CRB and would bring in the disclosure to show the manager. Other forms of identification were on some files, but not on others. The manager has drawer full of staff identification and information, this needs to be organised and filed on to the appropriate staff file. The manager was reminded of what information should be on staff files as detailed in Schedule 4 of the National Minimum Standards for Older People. Throughout the inspection it was evident that staff had the necessary skills and were competent to do their jobs. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The manager provides a standard of care that is consistent and reliable for people using the service. Quality assurance systems are in place to ensure the home is run in the best interests of the residents. The home has a satisfactory accounting system in place to safeguard resident’s finances. Policies and practices within the home promote and safeguard the health, safety and welfare of people living and working at the home. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has the necessary skills and knowledge to manage the home. The manager is a ‘hands on’ person and enjoys being with the residents. From observation and discussion with staff, residents and relatives, it was clear that the manager provides a good standard of care and is held in high regard. The manager knows every resident and what they care needs are. One relative spoken with said how good and caring the manager had been during their relative’s illness, they said the support offered had been invaluable. The manager agrees with the Inspector that office organisation is not her strongest point and would benefit from an administrator to assist in this area. The manager is working towards NVQ level 4 which hopefully will be completed by the end of 2006. Systems are in place for auditing and monitoring the quality of the service. This done through service user’s satisfaction questionnaires, staff and residents meeting. Monthly visit take place by a representative of the company as a written report of their findings is completed. The home also has achieved the Investors in People Award. The home holds personal allowances for the residents, if required. These were seen to be securely stored and in individual wallets. Four residents names were selected to check their finances. One maintains her own money, one had recently moved in to the home and personal allowance was still being sorted out and two residents wallets and balance sheets were checked and no errors noted. Information obtained prior to the inspection indicated that the handyman and external companies are responsible for the servicing of appliances for example gas, electrics, hoists and fire testing. The homes services manager was able to produce certificates verifying all checks had been carried out. Accidents, injuries and illness were suitably reported and recorded and the CSCI informed as required. During the course of the inspection safe working practices were observed within the home. Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 24 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 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP7 Regulation 15 Requirement Care plans must be agreed and signed by the resident or their representative. Progress sheets must be completed daily. Personal profile must be completed for all residents. All staff must undertake training in the Protection of Vulnerable Adults. The carpet in the middle lounge/ dining area must be replaced it is heavily stained. The patio area requires attention; it is untidy and needs the weeds removing. All staff files must contain proof of their identity. Staff files must be suitable organised and information securely filed. The manager must be able to demonstrate what training staff have undertaken, the dates and when refreshers are due. A copy of the training programme must be forwarded to CSCI. Copies of staff training certificates are to be kept on file. Timescale for action 18/08/06 2 3 OP18 OP19 13 16 18/08/06 18/08/06 4 OP29 Schedule 2. Reg 7,9,19 18 18/08/06 5 OP30 18/08/06 Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 26 6 OP31 9 The manager must ensure that all paperwork is organised and completed as required. 18/08/06 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. Refer to Standard OP27 Good Practice Recommendations The staffing levels at night should continue to be reviewed to ensure the changing dependency levels of resident’s are met. Staffing levels, mainly at the weekend should take in to account that the senior carer has the responsibility of managing the home in the absence of the manager. Therefore she may not be able to assist with providing care leaving the floor short staffed. 2. OP30 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 the end of 2006. 3. OP31 Ancliffe DS0000005721.V294573.R01.S.doc Version 5.2 Page 27 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 © 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 Ancliffe DS0000005721.V294573.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!