CARE HOMES FOR OLDER PEOPLE
Annacliffe Residential Home 129/131 Newton Drive Blackpool Lancashire FY3 8LZ Lead Inspector
Mrs Jackie Riley Unannounced Inspection 8th November 2005 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 Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 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.V264914.R01.S.doc Version 5.0 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 301955 Annacliffe Ltd Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 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) 16th August 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 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. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory inspection for 2005-06. It was unannounced and undertaken during a weekday period. The inspection examined a number of standards, including medication, financial management, staff training and health and safety issues which will be focused upon in the main body of this report. During the inspection the registered manager and individual staff members assisted the inspector with the process. A number of residents and staff were spoken to generally throughout the inspection process and comments will be included in the report. What the service does well: What has improved since the last inspection?
The home has reviewed and designed recording systems, which will greatly improve the level of recording. Staff training has been updated including moving and handling, first aid, medication training and health and safety have taken place for all necessary staff. The home has moved towards developing a range of activities specifically designed for residents who suffer from various levels of dementia. This will ensure they are socially stimulated using a range of programmes designed for them. Communication with residents is good, with a commitment by the management and staff to make sure residents or their advocates are informed of any changes, which may take place and affect them personally. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 6 There have been no changes in the staff team since the last inspection. However the manager demonstrated an awareness of the need for appropriate police checks prior to staff commencing work in the care home. There has been a positive development in the arrangement for activities. A notice board informs residents of forthcoming events, and there was evidence of two recent parties held at the care home. One resident spoken to said, “ we had a really good time and it was nice to see the staff with their families enjoying themselves”. There is development in the systems used to develop and maintain the care planning process for residents. This ensures that needs can be clearly identified and updated so that residents receive the appropriate level of care identified by the home. 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.V264914.R01.S.doc Version 5.0 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.V264914.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 There is little evidence of assessments in place prior to admission to the home, potentially putting residents at risk due to the lack of information in place. EVIDENCE: Four residents records were examined and there was no evidence of pre admission assessment either by the home or by social workers, thereby limiting the amount of knowledge about individual needs. Staff said, “Social workers always tell us about the needs of the person and we carry out own assessment based on what they say”. There was evidence to support a new assessment programme being introduced, which will provide a clear assessment format including all areas of need and a defined pre admission document. Management and staff spoken to were clearly aware of the individual needs of residents living there, so that they knew the level of care individuals require. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents health and personal needs are recognised and recorded on individual plans, but records were incomplete and not always reviewed so there is little evidence of all health care needs being met. EVIDENCE: There were individual records recording the health care needs of residents living at the care home. However in some instances they were incomplete, with little or no evidence of review thereby reducing the amount of knowledge required by staff to deliver a satisfactory level of care. A new computer system for the recording and maintenance of care planning is shortly to be introduced. This will enable management and staff to maintain records more accurately, so that they can be monitored and updated more closely for the benefit of residents living at the care home. Medication management is recognised as an important area for high maintenance by the senior management team. This is done by ensuring staff responsible for medication management have received appropriate training, so that residents and staff responsible for this are protected.
Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 10 There was evidence of residents Privacy being protected by way of appropriate locking mechanisms in bathroom, toilets. Locks on residents doors are used by way of basing a decision on risk for the health safety and welfare of residents accommodated. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 A revised activity programme has been introduced so that residents have their social and recreational interests met. EVIDENCE: There was evidence seen of a revised activity programme with a dedicated person acting as co coordinator. This now ensures individual interests are met as well as providing social stimulation in the form of parties celebrating occasions throughout the year. A staff member said, “we all got together to celebrate Halloween, and bonfire night and the residents really enjoyed themselves”. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 12 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 Complaints are handled objectively and responded to appropriately. There is a vulnerable adults procedures, which is used in induction and training to ensure residents are safeguarded from abuse. EVIDENCE: There have been no complaints investigated by CSCS since the recent change of ownership in July 2005. Staff spoken to were confident in the homes complaints system, and new that the procedures were there to protect residents and themselves. Some staff members have had training in the area of adult protection and whistle blowing, therefore are equipped to identify abuse and act upon it appropriately. All other staff have been identified to attend this training, which is planned to take place in the homes training room. The whole staff team will then be equipped with the knowledge and skills for the protection of users of the service. Suitable systems have been introduced to report all significant matters that occur. There were no outstanding complaints or issues on going at the time of inspection. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 13 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): 26 The home is clean and hygienic throughout for the comfort and safety of people living and working there. EVIDENCE: There is a designated staff team, who are responsible for the cleanliness and high standard of hygiene throughout the home. This ensures that the health safety and welfare of people living there is protected in addition to making sure the home is clean and pleasant for any stakeholder of the service. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 14 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): 30 The staff team are trained in areas to meet the needs of residents living at the care home. EVIDENCE: There has been development in the area of training making it accessible to all levels of staff. This can be carried out on the premises in a designated training room, thereby creating little disruption to the home. The management team are currently identifying individual training needs through the supervision process so that training specifically designed to meet the needs of residents can be arranged. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 15 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): 33, 35, 36. & 38 The home is well managed and run efficiently providing a safe and stable environment for people living there. Staff are supported and feel confident in the way the home is managed, as well as ensuring the home is run in the best interests of residents. EVIDENCE: Since the last inspection the registered manager has left the homes employment. Another manager has been appointed and is to make application to register. The management structure makes sure there is shared responsibility in the operation of the home. Staff spoken to commented on how supported they felt. One staff member said; “I know I can always rely on the manager to get things done”.
Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 16 The home has been awarded with Investors in People, which helps staff develop in training and improves the quality of service they provide in their work. The manager is supported by the registered provider, who work jointly in the decision making process, in order to ensure all residents and staff needs are met. Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 17 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 2 X 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 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 3 Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 18 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 OP3 Regulation 14 Requirement There must be evidence all residents have a full assessment in place at the time of admission. Timescale for action 31/12/05 2 3 OP31 OP7 8 15 Application must be made for the 31/12/05 manager to be registered by the Commission. All care plans must be complete 31/12/05 and contain evidence of regular review. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Annacliffe Residential Home DS0000064175.V264914.R01.S.doc Version 5.0 Page 19 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
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