Inspection on 12/10/06 for Annacliffe Residential Home

This inspection was carried out on 12th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Annacliffe Residential Home 18/09/08

Annacliffe Residential Home 08/11/05

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

CARE HOMES FOR OLDER PEOPLE Annacliffe Residential Home 129/131 Newton Drive Blackpool Lancashire FY3 8LZ Lead Inspector Mrs Jackie Riley Unannounced Inspection 09:30 12 October 2006 th 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 Annacliffe Residential Home DS0000064175.V299244.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. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Annacliffe Residential Home Address 129/131 Newton Drive Blackpool Lancashire FY3 8LZ 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) 01253 301955 01253 399455 Annacliffe Ltd Mrs Carol Ann Almond Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum number of 42 services users in the category of OP (Older Persons over the age of 65 years) 8th November 2005 Date of last inspection Brief Description of the Service: The home provides residential care for people of both sexes over the age of 65 years. A wide range of facilities and services are available for service users accommodated within the home. These include a laundry service, hairdressing, and Chiropody. The home also has extensive grounds with a bowling green and patio areas which are accessible to service users. Ramps are provided for wheelchair access. Aids and adaptations are in place to meet the needs of an elderly residential group. The home is situated in a residential area on a main road, with a good transport network close by. The home has two floors with both lift access and chair lift access to the first floor. There are currently 42 single rooms all en-suite. The home has a Statement of Purpose and Service User Guide providing information about the care provided, the qualifications and experience of the owners and staff and the services residents can expect if they choose to live at the home. A copy of the Service User Guide and most recent inspection report is issued to all prospective residents and their relatives/representatives to help them make an informed choice whether to move into the home. At the time of the inspection the fees ranged from £291.41 to £375.00 per week. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key service inspection undertaken during a daytime period, it was unannounced and carried out over a seven hour period. One inspector undertook the inspection. The inspection process included examination of records, discussion with the registered manager, staff and residents. Information received prior to the inspection included three resident comments, which showed they are satisfied with the level of care and services they receive at the home. There have been no complaints received by Commission for Social Care Inspection (CSCI) since the previous inspection. The home is not registered to provide intermediate care. What the service does well: What has improved since the last inspection? There is evidence residents are consulted about any changes, which may occur in the home and affect them in any way. Comments included “ the staff always let you know when your room is cleaned, so I like to go and sit in the lounge”. Staffing has been reviewed to make sure there is a skill mixture of staff to meet resident’s needs. Staff supervision is being developed and has improved since the previous inspection so that staff are supported in their work and training and development. Staff spoken to commented on how they feel supported by the management team. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 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. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 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 Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 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): 1,3 The quality outcome is good. This judgement was made using available evidence including a visit to the service. Prospective residents have information to make an informed choice about living in the home. Assessment information is available but contained within a number of documents which make the information difficult to access. EVIDENCE: The home provides information relating to the home and the services it provides. Residents spoken to were aware of this information and one resident said it was very helpful. Three residents files were seen, they included information about the residents, and the level of care to be provided. One file was for a resident privately funded and provided the homes assessment plan identifying the needs of the resident prior to admission. Two other files had assessments in place to inform staff of the individual needs. Discussion with the management team highlighted how problematic it was to gain this information at times prior to Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 9 admission, however the home was advised that this information is essential in identifying an individuals needs at the point of admission. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality outcome is good. This judgment was made using available evidence including a visit to the service. Healthcare needs are met by the home, however they could be compromised due to a lack of information on some records. Medication management is generally good however it would benefit from review so that the system is safe. Resident’s privacy is recognised and respected at all times. EVIDENCE: The home focuses on the specific needs of residents, with evidence of access to healthcare professionals including, dentists and opticians. A resident spoken to commented on how the staff team assist with specialist appointments when necessary. It was noted through observation of three resident files that in one instance there was no record of a residents specific healthcare needs, and the service user plan was not complete thereby having the potential for staff to be misguided in what the specific needs of this person is. It was noted the revised service user plan is not being used in accordance with the reference points it contains, in that information is held in other records. It would be beneficial for Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 11 the one document to be used, so that information is stored for each resident centrally making it easier to audit. The staff team are highly motivated and demonstrated a good sound knowledge of residents living in the home. They gave examples of some of the idiosyncrasies demonstrated by residents. There was no evidence of staff being judgemental in any way. One staff member commented, on how they like things to be carried out in certain ways, and that staff respect this however odd it may seem. Medication procedures are in place to ensure residents are provided with their medication safely. Storage is good in that there is a designated locked room for the safe storage of medication. However there was evidence of an excess of some medication, which required review and return so that it was not stockpiled and prescriptions may be reviewed and make changes accordingly to avoid excess medication being stored for any one resident. There are designated staff that are responsible for medication and all those staff have received recent training by the pharmacist, so that they are competent in administering medication. The home takes residents rights to Privacy and Dignity seriously, in that residents are assisted in personal tasks in a sensitive manner. Staff spoken to said “ we always make sure doors are closed”. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 The quality outcome is good. This judgment was made using available evidence including a visit to the service. Contact with families and friends is encouraged and supported by staff to maintain relationships. Activities are centred on resident’s interests; however there could be more choice available. Meals are varied and wholesome with choice provided ensuring residents dietary needs are met, however consultation with residents would identify individual choices. EVIDENCE: Visitors are encouraged to visit the home at any time so that residents continue to have contact with family and friends. At the time of the visit to the home, there were visitors coming and going. Visitors spoken to said they were generally pleased with the level of care their relatives receive. They commented about the high level of support provided by staff and how helpful they are to both residents and visitors. There is an activity programme in place, however residents spoken to spoke of how they don’t always like “what’s going on”. A resident spoken to said they would like to be involved in participating activities including baking, and handicraft type activities. This may be an area for future development. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 13 The home has a four-week cyclical menu. The menu appears well balanced and residents spoken to say they were generally pleased with the menu, however some residents commented on how they would like to be involved in any changes when the menus are reviewed so that they can include their favourite choices. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 14 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): 16,18 The quality outcome is good. This judgement was made using available evidence including a visit to the service. The arrangements for recording and reporting of complaints are good ensuring people feel listened to. Management and staff displayed a good knowledge and understanding of adult protection issues, thereby protecting residents from abuse. EVIDENCE: The home has a detailed complaints procedure, which is made available to all residents and relatives on admission. One resident said, “If I’m not happy with something I know who to go to and what to do”. There have been no complaints since the previous inspection. Staff spoken to are aware of the complaint and abuse procedures, so that people are protected. There was evidence of staff attending training in this area, it is also an area completed during the induction period so that all staff have an awareness of the procedures, which are in place for the protection of all users of the service. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 15 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 The quality outcome is good. This judgement was made using available evidence including a visit to the service. Residents live in a safe, clean and tidy environment. The home is maintained to a high standard ensuring the residents comfort and safety in pleasant surroundings. EVIDENCE: There is a continuing commitment by the home to make sure the environment is comfortable for residents to live in. Rooms seen are personalised and homely. Residents spoke of enjoying the use of the lounge areas in the home where “we can have a good natter”. There are a range of aids and adaptations in place so that residents can move around the home safely. It is a large home, but residents spoken to commented on how they like to use specific lounges and their own rooms whenever they choose. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 16 There is a designated maintenance employee, who is responsible for the general upkeep of the home. Staff spoke of using the maintenance record to report anything they think needs attention. Residents spoke of how they like to use the rear garden area, which is large secluded and well maintained, so that it is a pleasant place to spend some time. Access to this area is good for people in wheelchairs or with limited mobility. Discussion with residents confirmed the rear lounge would benefit from a ramp instead of the step in place for residents with mobility problems. Two residents spoken to using walking aids said, “it was difficult at times”. The home is clean and designated staff are employed for domestic tasks. Staff spoken to were knowledgeable about the need for infection control and the systems in place at the home for the control of infection. It would be beneficial for staff to undertake periodic infection control training in order to be familiar with current good practices. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 The quality outcome is adequate. This judgement was made using available evidence including a visit to the service. Staffing levels in the home are satisfactory to meet the needs of users of the service. Recruitment of staff is taken seriously however some records were not complete, thereby having the potential to put people at risk. Induction training information is limited and does not thoroughly confirm staff competence. EVIDENCE: The staff team are highly motivated and committed to carry out their roles to ensure resident’s lives are made as comfortable as possible. Staff spoken to say they feel supported by the management team. Training is taken seriously and all staff are encouraged to attend a variety of training courses appropriate to meet the needs of residents. Staff members spoken to commented on the range of courses they have attended and are to attend in the near future so that staff are equipped with the skills to carry out their roles competently. There is a staff induction record however this record does not clearly provide enough evidence of how competent the employee is in the various areas checked. More information would benefit this document and provide a baseline for further training needs. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 18 Recruitment is taken seriously by the home, however it was noted there are instances where staff have been recruited without evidence of references being checked and verified prior to commencing employment. Fitness checks must be completed prior to staff commencing employment so that all users of the service are protected. Staffing levels are in place based on meeting the needs of residents living in the care home, however comments received suggested the staffing levels for weekends be reviewed. Some comments suggested staff aren’t always available when visitors arrive and “they are thin on the ground”. Observation of staffing rotas showed a minimum staffing ratio, which can be compromised due to sick leave without notice. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 19 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 The quality outcome is good. This judgement was made using available evidence including a visit to the service. The range of management and administration systems means that a competent management team effectively manages the home, but monthly quality monitoring by the area manager is not occurring. EVIDENCE: The way the home is run means that it provides overall quality in its delivery of services and care to resident’s staff and all stakeholders of the service. A clear management system makes sure this is achieved. Observation of management systems confirmed they are effective in how the home is generally managed, in that the manager has sound knowledge of management and financial budgeting of the service, resulting in the service meeting its stated aims and objectives. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 20 The manager makes sure staff know about the policies and procedures to follow through supervision processes, so that they are competent in all areas. Quality monitoring is in place through regular discussion with stakeholders of the service and staff meetings so that the home can measure its effectiveness. Residents and relatives are encouraged to manage their own financial affairs, however two residents receive personal allowances, which are individually recorded and signed for with witnesses so that there is protection. It was noted the registered person visits the home on a regular basis, however there is a requirement for a report to be copied to the Commission following a monthly unannounced visit to the home to look at all levels of its performance with comments if necessary. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 21 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement There must be evidence medication management is reviewed and appropriately recorded to ensure a safe system. All staff files must have information as set out in Schedule 2 prior to commencing work in the care home. The registered provider must provide a copy of the monthly unannounced visit report to the Commission, providing information about the findings of the visit relating to how the home is being run. Timescale for action 30/11/06 2. OP29 19 30/11/06 3. OP31 26 30/11/06 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 OP7 Good Practice Recommendations All service user plan information should be kept together DS0000064175.V299244.R01.S.doc Version 5.2 Page 23 Annacliffe Residential Home 2 3. 4. 5. 6. OP12 OP15 OP26 OP27 OP30 to ensure a clear audit trail. The home would benefit from looking at the range of activities residents may like to participate in. The use of quality monitoring for choice of meals would identify some of the resident’s favourite choices, which could be included in the meal planning process. The staff team would benefit from Infection Control training to update on current good practice. Staffing levels for the weekend staff team should be reviewed so that there are always sufficient staffing levels on duty to meet the needs of residents. The induction training programme should demonstrate more information about an individual’s competence in any of the tasks assessed. Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Annacliffe Residential Home DS0000064175.V299244.R01.S.doc Version 5.2 Page 25 - 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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