Inspection on 27/02/08 for Ancliffe

This inspection was carried out on 27th February 2008.

CSCI found this care home to be providing an Poor service.

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

Ancliffe 26/06/06

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 27 February 2008 09:45 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.V343649.R02.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.V343649.R02.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 kath.ryan@clsgroup.org.uk www.clsgroup.org.uk CLS Care Services Limited 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) 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.V343649.R02.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 26th June 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. 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.V343649.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use the service experience poor quality outcomes. This inspection included a site visit which the manager and staff of the home did not know was going to happen and was conducted over 6½ hours. At the time of the inspection the home’s manager was on leave, the homes service manager was available to assist with the inspection. Part of the time was spent in the office looking at the information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. The inspector spoke with staff and residents throughout the course of the day. The inspector also looked around the home and checked some of resident’s bedrooms for cleanliness and comfort. Prior to the inspection the home was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment form that provides the inspector with information about what the home does well at, what improvements they have made and in what areas they need to improve. To find out more about the home, comment cards were sent to residents, relatives, and to other people who visit the home such as doctors and district nurses. Four residents, four relatives, and three doctors returned comment cards. There were no added comments on the resident’s surveys, however responses indicated their overall satisfaction about the home and the services provided. One relative said, “They look after people who need help and always give them things to do so they don’t get bored”. Another said, “I am very satisfied with the care my father receives”. The returned comment cards from the doctors expressed their satisfaction about the care their patients received at the home. There have been no complaints made to the manager of the home and no complaints have been forwarded to the CSCI. Following the inspection, three immediate requirements were left. An immediate requirement is made when the inspector has some concerns about practices within the home. An immediate requirement must be responded to within 48 hours informing the CSCI how these concerns will be addressed. The immediate requirements were as follows: * That all staff must undertake and update mandatory training as required. * That all staff must undertake training in the protection of vulnerable adults Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 6 or receive refresher training as required. (Outstanding from the last inspection) * That the manager must ensure that all the paperwork required by regulation is completed and is up to date. (Outstanding from the last inspection). What the service does well: What has improved since the last inspection? What they could do better: As the home is offering care for some residents with a diagnosis of a dementia related illness all staff would benefit from training in caring for residents with dementia. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 7 Mandatory training must be completed by all staff and regular updates as required arranged. Resident’s bath charts and records of weights were incomplete in the four care plans inspected. The outside patio area and gardens require attention. There was evidence of an ashtray overflowing with cigarette ends, buckets, rubbish bags and drinks cans. This looked unsightly. The designated smoke room should not be used for storage. On the day of the inspection there were three small TVs stored, plus the main one, also a wheelchair and an empty drugs trolley. Attention should be given to the notices on certain doors, for example the hairdressers door was unlocked and shampoos etc were on view despite the notice stating, ‘door to be kept locked’, also a wheelchair and detached footplates were in the staff toilet, when a notice requests that wheelchairs and footplates should not be stored there. The home would benefit for some storage space for wheelchairs etc. 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. Ancliffe DS0000005721.V343649.R02.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.V343649.R02.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): 1,2,3 and 4 were assessed. Standard 6 does not apply at Ancliffe as the home does not offer an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their supporters are provided with up to date information that helps them in making a decision about moving into the home and the services provided. EVIDENCE: The home has a statement of purpose and a service users guide. This information is available on the information table in the main corridor. There is also a Welcome Pack and a photograph album to show prospective residents what goes on in the home. The CSCI report is available for all to read. We chose four residents care plans for inspection. On examination all four contained a pre admission assessment. The pre admission assessment is Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 10 completed at the most convenient place for the prospective resident and is carried out to ensure that the home and staff can meet the individual needs of the resident. The assessment includes, residents details, medical conditions, cognitive patterns, hearing, communication, vision, moods and behaviour, well being, mobility, continence, bathing, dressing, personal hygiene, foot care, pain systems, nutrition, oral care, skin condition, sleep patterns and medication. The home was able to evidence that all of the four residents whose care plans we looked at had a written contract/ statement of terms and conditions, regardless of how their care is purchased. These are kept separately from the main care plans in a secure location. The home is offering care for up to five residents with a diagnosis of a dementia related illness. Most staff at the home had not undertaken any dementia training; therefore staff cannot be certain that they are offering the best care available to those residents. Staff spoken with told the inspector that they feel that they would benefit from training in this area. Ancliffe DS0000005721.V343649.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the information in the care plans had not been completed, this could result in some aspects of care being overlooked and could be detrimental to the residents health and wellbeing. EVIDENCE: We continued to inspect the same four care plans. There was some good information documented and all but one plan was written in a person centred way, for example, I need help with, I can walk unaided, I like to go to bed late, I like tea in a morning at 07:00 am with sugar. The manner in which the care plans are written is more personal and involves the resident as much as possible. In one care plan the old format is still being used. There was evidence to say that in three care plans that residents had given their consent for photographs to be taken, access to records, training, self Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 12 administration of medication, laundry, care plans, statement of terms and conditions and personal allowances had been agreed. This agreement was incomplete in the last person’s file that moved in to the home in January 2008. One care plan had not been updated monthly as required with the last update being 23 November 2007. In all four care plans there were gaps in bathing and weight records. One care plan showed that from 8 August 2007 to the 22 February 2008 the resident had only been weighed twice, there was nothing documented to say the resident had refused to be weighed or for some reason could not be weighed. There was also nothing recorded for bathing, and for example from 8 September 2008 to 7 October 2008 no baths or strip wash was recorded. In another care plan the bathing chart showed on 25 July 2007 the resident was bathed, it is documented that that the resident requested a bath on 11 August 2007 there was nothing recorded to say this request had be carried out with the next recording being the 16 August 2007, with baths then following on 28 August 2007, 18 September 2007, 30 October 2007, 26 November 2007, 26 January 2008. This record indicates that the resident is only being bathed in some cases once a month and within those dates had only been weighed three times. This care plan had been updated on 18 February 2008. There was evidence that risk assessments had been carried out for falls and moving and handling and nutrition, however some needed updating to ensure that the information is current and up to date. Care plans contained information to show that the health care needs of the residents were being met and that outside agencies such as the district nurse, the doctor, chiropodist, optician are contacted as required and their advice acted up on. Observation throughout the inspection showed that the personal care needs of the residents were being met. Attention to all residents was given to personal grooming, residents were seen to be clean and clothes had been nicely laundered. Ladies had had their hair done and the gentlemen were cleanshaven. There was a good atmosphere within the home and the inspector heard staff speaking with residents in friendly and respectful manner. It was evident that good relationships had been formed between the residents and with staff. Staff were observed knocking on bedrooms and toilet doors and waiting for a response before entering to ensure the residents privacy and dignity was respected at all times. The care team leader gave out the morning and lunchtime medication round; tablets were dispensed swiftly and efficiently with a drink of the resident’s Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 13 choice. Medication was recorded on the individual’s drug sheet immediately after the tablets had been given. The inspector checked the medication with another care team leader at the change over of shifts and all medication had been given and could be accounted for. The home holds some controlled drugs, these were checked against the records and no discrepancies were found. Ancliffe DS0000005721.V343649.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a wide and varied range of activities to suit their capacities and expectations. EVIDENCE: The homes activities coordinator plans a good range of activities both indoors and trips out for the residents. One resident told the inspector about her trip out to the a garden centre with the activities coordinator and how she had enjoyed the day especially the tea and toasted teacakes they had in the café. Residents had made cards in the arts and craft sessions, which were for sale in the hallway. Other residents said they had won prizes at the bingo the night before. Other activities with in the home included a range of board games, a film club, knitting, shopping trolley and visits from entertainers. The activities coordinator is flexible and will change the times of her day to suit the needs of the residents. The home now has a computer for the residents to use if they wish. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 15 Visitors are welcome to visit at any time; there are no restrictions as to when people can visit. Residents can meet with their visitors in any of the lounge/dining rooms or in the privacy of their own room. One visitor often brings a dog to visit; one resident said how she looked forward to seeing the dog. The manager encourages links with the local community and welcomes different groups to visit. The home has regular visits from the local clergy who offers communion for those who wish to partake. Residents told the inspector that they could make their own choices about how they spend their day, one resident said, “ I get up when I want and usually go to my room after my tea to watch my television. If I want to join in with any of the activities I can, it’s up to me”. Residents spoke about the meals at the home and said how good they were, that there was always a good selection offered at every meal. A flexible breakfast is served until mid morning, so that resident can have a lie in if they wish. On the day of the inspection the choices included: porridge, cereals, eggs, bacon, tomatoes, toast and preserves and tea or coffee. During the course of the morning staff go round and ask what resident would like for lunch and dinner. A lighter lunch was offered with a choice of oxtail soup, ham, cheese or salmon sandwiches, beans on toast, or jacket potatoes followed by banana and custard or fruit. At lunch time staff asked residents what sandwiches they would like and how many. Staff wore appropriate clothing when serving food and used tongs to serve out sandwiches. Early evening dinner is the main meal of the day and residents had a choice of roast chicken, creamed potatoes, mixed vegetables and gravy or poached fish or sausage rolls with the creamed potatoes and vegetables followed by homemade cakes. It was noted that the dining tables were nicely set with tablecloths, napkins, appropriate cutlery and condiments and insulated drinks jugs of tea or coffee with milk and sugar on every table. Suppers are available with a choice of snacks and drink of the residents’ choice, including hot milk drinks. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 16 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 and 18 were assessed Quality in this outcome area is Adequate This judgement has been made using available evidence including a visit to this service. Residents and their supporters can be confident that any concerns or complaints would be listened to and appropriate action taken. EVIDENCE: A complaints procedure is in place along with a complaints file. There are no recent complaints in the file. The information on the returned AQAA states that there has been no complaints made to the manager of the home with in the last twelve months. There have been no complaints brought to the attention of CSCI. All staff complete a staff induction programme on commencing work at the home, which covers areas of adult protection. This is also covered in NVQ level 2 training. For all staff, training in the protection of vulnerable adults should be updated every two years so that staff are kept informed of any new polices and procedures and to ensure that they have the confidence and knowledge to deal with any issues of abuse that could occur. There have been no safeguarding issues reported by the home within the last year. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 17 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): 19,24 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Ancliffe is maintained to a good standard making it a homely, comfortable, clean and pleasant home for residents to live in. EVIDENCE: From a tour of the premises, it was evident that there is an on going programme of maintenance in place. New flooring had been laid in the middle lounge/dining area. A new bath was being fitted in one of the bathrooms. All the communal areas were comfortable and clean. The small dining room has now been changed in to the designated smoke room with an extractor fan fitted. This room required tidying up as it appeared to be being used for Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 18 storage purposes. The previous smoking area has now been changed into an activity room. A selection of resident’s bedrooms was looked at. These were found to be clean and tidy and comfortable. Residents had personalised their rooms with their own possessions brought with them from home. Bathrooms were nicely decorated, with domestic style features to enhance a relaxed atmosphere for residents when bathing. In all toilet cubicles there was a good supply of liquid soap and paper towels. It was discussed with a member of the domestic team about the flooring in some of the toilets. On some of the lighter flooring it was seen that the floors were stained and had black marks on it. The floors were not dirty and this could be down to rubber off the zimmer frames and wheelchairs. Consideration should be given to replacing the stained flooring. The home was cluttered with wheelchairs and although storage space may be a problem, consideration should be given to suitable storage when wheelchairs are not in use. A wheelchair with detached footplates was stored in the staff toilet, when a notice was displayed asking for wheelchairs not to be stored in there. The inspector checked the hairdressing room door and found this to be open when there is a notice stating that the door should be kept locked. It was seen that hair products were easily accessible and could pose a risk to some residents. The salon door when checked again was found to be locked. The outside grounds of the home require attention. Patio and seating areas were untidy. Areas used by staff had an ashtray overflowing with cigarette ends; some of these were on the floor. There was an empty drink tin and garden rubbish bags that also need to be removed. Systems were in place to control the risk of cross infection. Staff were seen wearing different protective clothing when carrying out different tasks. Any person entering the kitchen must put on a white overall. The laundry is sited away from the food preparation and food storage areas and does not intrude on the residents. The laundry door was locked. The inspector spoke with a member of the domestic staff, who obviously enjoyed working at the home and took pride in her work in helping keep the home clean and free from any offensive odours. Ancliffe DS0000005721.V343649.R02.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 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all staff had undertaken the necessary training to ensure that the safety and wellbeing of the residents is protected and promoted. EVIDENCE: The staff rotas were available for inspection and gave an accurate record of the staff on duty. Consideration needs to be given to staffing levels taking into account that five people have a dementia related illness and the recommended guidelines are one member of staff to five residents with dementia and one member of staff to ten residential people. There were thirty-seven residents in the home on the day of the inspection. Three care staff were working the floor, the care team leader assists on the floor when needed and gives out the medication, which in a morning can take a long time. The inspector appreciates that the activities coordinator was also on duty, however not in a caring role. Staffing levels should be constantly reviewed given the layout and size of the building, the staff on duty and their role. There are two waking night staff on duty each night. Several of the staff had worked at Ancliffe for a number of years and staff morale appeared very good. From discussions, staff showed they know the Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 20 residents well and showed commitment to providing a good standard of care. Staff were clear about the work they were employed to do and that they were happy to help each other out. Domestic staff and kitchen staff are employed in sufficient numbers to cater for the needs of the residents and to support care staff. A copy of each members of staff’s employment file is kept at the home in a secure location. The file for the last most recently recruited employee was looked at and was complete and up to date. Three other files of longer standing members of staff were also examined. Files contained copies of CRB disclosure numbers, application forms, one file from a long standing member of staff did not have two written references, the other two files had references, employment details and other forms of identification such as copies of passport, birth certificates etc. All new staff completes an induction programme on commencement of work. Staff spoken with was unsure of dates of training or if they were overdue refresher training. Some staff said they feel they would benefit from dementia training as the home was offering care for residents with a diagnosis of dementia. From the information available some staff were overdue moving and handling training which is essential to residents and staff safety as staff were seen transferring people from chairs to wheelchairs and hoisting another resident. It was difficult to assess what training had been undertaken as there was little evidence of up to date staff training certificates. An immediate requirement was made with regard to staff training. Ancliffe DS0000005721.V343649.R02.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 and 38 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home’s manager is suitably experienced and qualified and ensures the residents are well cared for, there is an oversight in the administration and organisation of the upkeep of the paper work required by regulation. EVIDENCE: The home’s manager has a significant number of years experience in working with elderly people and is qualified to NVQ level 4 in care. The manager ensures that the residents living at the home have the things they need to Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 22 make their life as comfortable as possible and both staff and residents spoke favourably about the manager and her caring skills. The manager operates an ‘open door’ policy so that she may be approached at any time by staff or residents or their families. The office needs to be better organised so that all the information is up to date and easily accessible, for example checking that all the information in the care plans is up to date and records are being completed. That training is planned in advance and the training records are up dated as required with evidence of certificates in place to verify what training staff had completed. There was information recorded in the Fire Occurrence book regarding the alarm system, resulting in the fire brigade attending, not all the information was detailed or dated. An immediate requirement was made regarding poor recording and incomplete information. Quality assurance systems were in place. These included monthly visits from senior management who visits the home and completes a written report of their findings, these were available for inspection. Residents meeting are held with the last one being on the 9 January 2008. With regard to staff meetings, there appeared to be a long period of time elapsed between the Care Team Leaders meetings as the minutes available were 31 January 2007 with the next meeting held on 28 January 2008. Care staff had a team meeting this year but no dates were recorded to say when. Other care staff meetings were documented with dates 18 August 2006 and 3 February 2007. The home’s service manager held a meeting with domestic staff on 21 January 2008 and minutes were available for inspection. The home has achieved the Investors in People Award and has been awarded a five star rating by RDB (Residential Domiciliary Benchmarking). RDB is an independent company that inspects the home and awards a star rating. RDB has no connection with CSCI. Policies and procedures were in place. According to the information provided by the manager on the completed AQAA some have not been reviewed for some time for example Confidentiality and Disclosure November 2004, Pressure Relief September 2004, Management of Service Users Money, Valuables and Financial Affairs March 2000. Policies for Death of a Service User, Equal Opportunities, Diversity and Anti- oppressive practice, Values of Privacy, Dignity, Choice, Fulfilment, Rights and Independence indicates they are in place but review dates were not provided. Some residents living at the home have a small amount of money with the manager for safekeeping. We checked the money for the four people whose care plans we had looked at, two of the residents dealt with their own finances, a third the family dealt with all monies and the fourth had a small amount in a Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 23 separate wallet kept in the office. This was counted and the balance sheet was correct. Information on the AQAA was not able to tell the inspector that all equipment had been serviced as required, for example there was no date for the testing of the premises electrical circuits (usually 5 years), gas appliance (annually) was October 2006, the certificate for 2007 was not seen, however one was available for January 2008. The bath hoists were checked in October 2007, from checking fire extinguishers these had been checked on May 2007, however no certificates were available. Information was provided that demonstrated that some of the electric portable appliances had been tested in February 2007. The manager needs to ensure that regular fire drills are carried out, the date of the last one being recorded as 9 August 2007. Safety notices are posted to alert staff to possible hazards, these were not being adhered to in some instances. Accidents, injuries, and incidents were recorded and the CSCI informed as required. Ancliffe DS0000005721.V343649.R02.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 3 3 3 2 x x 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 3 x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 25 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 OP4 Regulation 18 (1) (c) Requirement Timescale for action 27/06/08 2. 3. OP7 OP18 15 (2) (b) 13 All staff must undertake training in dementia care, to ensure that residents who have a diagnosis of dementia are being cared for by suitably trained staff. The residents care plans must be 28/03/08 kept up to date and under review. All staff must undertake training 29/02/08 in the Protection of Vulnerable Adults. (This is outstanding from the last inspection with a timescale of 18/08/06. An immediate requirement was made and the CSCI to be informed within 48 hours of how this would be addressed). The patio area requires attention; it is untidy and the rubbish should be removed. The manager must be able to demonstrate what training staff have undertaken, the dates and when refreshers are due. (This is outstanding from the last DS0000005721.V343649.R02.S.doc 4. OP19 16 28/03/08 5. OP30 18 29/02/08 Ancliffe Version 5.2 Page 26 inspection with a timescale of 18/08/06. An immediate requirement was made and the CSCI to be informed within 48 hours of how this would be addressed). 6. OP31 17 (1) 17 (2) The manager must ensure that 29/02/08 all paperwork is organised and completed as required.(This is outstanding from the last inspection with a timescale of 18/08/06. An immediate requirement was made and the CSCI to be informed within 48 hours of how this would be addressed. An accurate record of every fire practice, drill, or test of fire equipment (including the fire alarm equipment) conducted in the home and any action taken to remedy defects in fire equipment. 28/03/08 7. OP38 17(2) Schedule 4. 14 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. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 27 2. 3. OP19 OP33 The home would benefit from some additional storage space. The frequency of staff meetings should be considered, to ensure the smooth running of the home. Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Ancliffe DS0000005721.V343649.R02.S.doc Version 5.2 Page 29 - 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. 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