Inspection on 13/09/06 for Anson Court

This inspection was carried out on 13th September 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 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

Anson Court 06/11/08

Anson Court 14/11/07

Anson Court 30/09/05

Anson Court 15/04/05

Anson Court 09/11/04

Anson Court 18/05/04

Anson Court 16/12/03

Anson Court 22/07/03

Anson Court 28/08/02

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

CARE HOMES FOR OLDER PEOPLE Anson Court Harden Road Leamore Walsall West Midlands WS3 1BT Lead Inspector Maggie Bennett Key Unannounced Inspection 09:35 13 September 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 Anson Court DS0000020842.V307816.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. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anson Court Address Harden Road Leamore Walsall West Midlands WS3 1BT 01922 409444 01922 409111 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) Manor Court Health Care Limited Mrs Mandy Jane Halls Care Home 33 Category(ies) of Dementia (33) registration, with number of places Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th September 2005 Brief Description of the Service: Anson Court is a purpose built two storey care home in the Harden area of Bloxwich. The home provides accommodation for 33 residents who are over 55 and whose mental health has deteriorated (as a result of dementia). The home is situated close to local shops. All bedrooms are single and have an en suite toilet facility. Communal space consists of a large lounge, one smaller lounge, a conservatory, which can be used by smokers, and a separate dining room. The home has an enclosed, secure courtyard garden area with raised flower beds. Entrance and exit to the main door of the home is via a security system and service users are unable to leave the home without staff assistance. The current charges at the home are £351.87 per week. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 2 days: 13th September 2006 from 9.35 a.m. to 4.35 p.m. and 15th September from 10.50 a.m. to 1.30 p.m. Prior to the inspection a questionnaire had been completed by the home and returned to the Commission. The home had not sent the Commission’s surveys to service users, relatives and social and healthcare professionals as they had just completed a survey of their own. Copies of the responses to these surveys were forwarded to the Commission. The Commission’s surveys are to be sent out in October 2006. During the course of the inspection the assessment information was seen for 3 service users and the care plans of another 4 service users were inspected. Medication administration was checked. Staff records were seen to check staff ratios, recruitment procedures and training. Various documents were seen in order to check compliance with Health and Safety legislation. A tour took place of the building. Two visiting relatives were spoken to during the inspection and a number of service users were spoken to throughout the day. Lunch was taken with the service users. Discussion took place with 2 members of staff. The Registered Manager was present throughout most of the inspection. On this occasion all the Key Standards of the National Minimum Standards were inspected. Following the last inspection, in September 2005, one statutory requirement was made. 7 requirements were made as a result of this inspection. What the service does well: Anson Court provides secure and comfortable accommodation for older people with dementia. Care is provided by a cheerful and well-motivated staff team, who are very well led by an experienced, committed Manager. During the inspection not all service users were able to express an opinion about the home, but those that did expressed their satisfaction. One person said: “I like it here, they are all so nice and friendly.” Visiting relatives also expressed their satisfaction, one saying that the care was “very good” and that they were always kept up to date with their relative’s well being. Full information is provided to prospective service users and their relatives prior to admission. The Manager insists on a full and comprehensive assessment prior to anyone moving to the home. The specific needs of the service users at Anson Court are well met, with staff receiving training in the care of people with Dementia. The Manager is a qualified Dementia Care Mapper, who has a thorough understanding of the needs of her service users. Service users are treated respectfully and their right to privacy is understood and upheld. Social care activities are provided on a daily basis (apart from Sundays) and care is taken Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 6 to ensure that these are appropriate to the service user group. The food provided at the home is of good quality and choices are always available. Staff receive training in Adult Protection and show a good understanding of their responsibilities with regard to the Protection of Vulnerable Adults. There are robust recruitment procedures in place to protect service users. The home takes steps to seek the views of its service users and their relatives through regular meeting and surveys. What has improved since the last inspection? 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. Anson Court DS0000020842.V307816.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 Anson Court DS0000020842.V307816.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): 3 (Standard 6 is not applicable). The overall outcome for this group of Standards is judged to be Good. Anson Court provides clear information to prospective service users and their families to enable them to make decisions about whether or not they wish to live at the home. All prospective service users receive a full assessment prior to admission to ensure that their needs will be met. EVIDENCE: The assessment information for 2 recently arrived service users and one prospective service user was seen at the inspection. The service users were not able to recall the assessment process, but the nearest relative of one said that they had been given full information about the home prior to making any decision and had had the opportunity to look around. In all cases the home had obtained full assessment information prior to the service users moving in and the Registered Manager had seen all 3 and had carried out her own assessment. One person was privately funded and the Registered Manager had carried out a full needs assessment covering all those areas detailed in Standard 3.3. There was a care plan in place for both of the service users who were now living at the home (see Standard 7). Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 9 Although not assessed on this occasion, there is evidence that the home continue to meet the needs of its service users. Staff demonstrate a good understanding of the needs of people with dementia and are provided with specialist training. Anson Court DS0000020842.V307816.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 and 10. The overall outcome for this group of Standards is judged to be Good. All service users have individual plans of care, which ensure that their personal, healthcare and social needs are met. Some of these care plans are in need of updating. Medication is administered and stored in a manner that safeguards service users. Service users are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: Six service users’ care plans were seen during the inspection. All contained details of the actions needed to ensure that the personal, social and healthcare needs of the service users are met. At present the care plans of the service users are kept together in several large files. It is recommended that care plans are kept within the service users’ individual files and that these are locked when not in use, to ensure confidentiality. All the care plans seen contained a risk assessment. There was evidence that both care plans and risk assessments are reviewed by the home on a monthly basis. The Registered Manager states that the situation with Social Work reviews has improved of late and that the majority of service users have now have an updated formal review chaired by a representative of Social Services. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 11 Although there was evidence of regular reviews, one care plan had not been updated since 2001 and another since 2003. It is unlikely that the care needs of these people have remained unchanged in this time. Care plans must be updated to reflect changing needs. A risk assessment seen had been updated to reflect the fact that the service user was now at an increased risk of falls. It is recommended that care plans contain more information on the process of care, i.e. how the service user prefers the care to be given. Service users’ healthcare needs are detailed within their care plans. The plans seen contained details of oral hygiene needs. Where service users are at risk of developing pressure sores, a pressure sore risk assessment is in place. Service users who are at risk are provided with pressure relieving cushions and mattresses. There is evidence that the Continence Advisor visits regularly. Service users take part in light exercise sessions on a regular basis. Care plans seen contained details of food likes and dislikes and of any difficulties with eating. Weights are taken regularly and the home shares a set of seated scales with 2 other homes within the Company. It is recommended that the Registered Manager obtain a copy of a Nutritional Screening Tool from the Dietician. There is evidence from care plans that service users have access to specialist healthcare professionals, including optician and chiropody. The Registered Manager states that there continue to be problems with accessing the NHS chiropodist as often as needed and that some service users’ families prefer to pay for a private chiropodist. The Registered Manager is proactive in ensuring that the service users’ entitlements to NHS services are upheld. There is evidence that service users’ medication is regularly reviewed by their G.P.s. The home has clear policies and procedures in place with regard to the administration of medication. It is recommended that the home include a policy on covert medication administration. There are no service users who take charge of their own medication, although some keep creams in their rooms. In these cases it is recommended that creams be locked in individual rooms when not in use. The home uses a monitored dosage system. Medication and administration records are delivered to the home every 2 weeks. Controlled drugs, when used, are correctly stored, administered and recorded. The temperature of the medicines’ refrigerator must be checked each day with a maximum/minimum thermometer and this must be recorded. A random sample of the medication and accompanying administration records were seen during the inspection and there were no discrepancies. Records are kept of all medicines returned to the Pharmacist. All those staff who administer medication have successfully completed accredited medication training. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 12 All service users have their own rooms at Anson Court and therefore all care giving and medical examinations take place in private. Service users are addressed using the term they prefer. All new staff receive full induction training, which includes information on how to treat service users with respect. During the course of the inspection there was a good example of staff understanding of a person’s need for privacy. Staff were seen to be taking care not to intrude on a new service user and to give her space to settle in. Her care plan stated: “very private person, resents intrusion into privacy”. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 13 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 and 15. The overall outcome for this group of Standards is judged to be Good. Service users are able to exercise choice with regard to recreational activities at the home. Activities provided meet the needs of the service user group. Relatives and friends are encouraged and assisted to maintain contact with the service users. The food provided at the home is of good quality and choices are always available. EVIDENCE: Service users are able to exercise choice as to whether they join in the activities organised at Anson Court. Meals are usually taken together, although during the inspection one service user, who made it clear that she did not want to eat in the dining room at lunchtime, was assisted back to the lounge and her meal was given later, at a time which suited her. Service users’ interests are recorded in their care plans. An appropriate activity is provided each day and service users decide for themselves whether or not they wish to take part. An Activity Organiser has just been recruited and will be visiting on a weekly basis. Not all service users are able to concentrate for any length of time, but during the inspection several were observed to be enjoying a musical activity, followed by bowls. Trips out for small groups of service Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 14 users are also organised. A trip to the Arboretum Lights is planned for next month. Service users are able to see their visitors at any reasonable time either in their rooms or any of the communal rooms. The second sitting room is rarely used by the service users and this is popular with visitors. The Service Users’ Guide contains information on the home’s policy with regard to maintaining relatives’ and friends’ involvement with the service users, once they have moved to Anson Court. Information on the local Age Concern Advocacy Service is available within the home. The Registered Manager gave an example of how advocacy had been used for one service user who had no next of kin to act on their behalf. All service users and their relatives have been informed in writing of their right of access to their personal records. Copies of these letters were seen in individual files. Menus seen at the inspection show that service users are offered a variety of nutritious foods. There is always a choice for each meal and if either choice is not liked, an alternative will be offered. During the inspection one service user requested a sandwich and this was provided. Drinks and snacks are provided between meals. Special diets are provided as required. At the time of the inspection the midday meal was either faggots and gravy with vegetables or corned beef with vegetables. During the inspection the meal was taken at a leisurely pace and those service users who needed help were given it discreetly. One service user was able to have her meal with her husband, who was visiting during the inspection, in private in the second lounge. The kitchen was inspected and was found to be in good order. There were ample supplies of food, including fresh vegetables and fruit. Records were seen to verify that fridge and freezer temperatures are taken each day and recorded. Service users spoken to during the meal said that they had enjoyed their meal. The Environmental Health Officer visited earlier in the year and the Registered Manager states that the recommendations made at the time have all been met. Several staff, including the Manager, recently attended a Food Hygiene Seminar. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 15 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 and 18. The overall outcome for this group of Standards is judged to be Adequate. There is a clear complaints procedure in place, a copy of which is made available to service users and their relatives. This should ensure that any complaints made are listened to and acted upon. The home has an Adult Protection Policy and Procedure to protect service users from abuse. This needs to be amended so that it is in line with the local Social Services Policy and the Department of Health document, “No Secrets.” EVIDENCE: There is a clear complaints procedure at Anson Court, a copy of which is made available to service users and their relatives. A bound book is kept in which to record complaints. No complaints have been received by the home, or by the Commission, since the last inspection. The home has an Adult Protection Policy and Procedure in place. This policy is not in line with the Walsall Social Services Policy and the Department of Health document, “No Secrets” with regard to the investigation of allegations. The policy must be amended to ensure that it is in line with these documents. The Registered Manager is aware of her responsibilities under the Protection of Vulnerable Adults guidance. Staff have attended training on Adult Protection issues and those spoken to during the inspection were clear of their responsibilities with regard to Whistleblowing. There is a policy in place with regard to any verbal or physical abuse from service users. There are also policies with regard to service users’ monies. For further assessment on this issue, see Standard 35. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 16 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, 24 and 26. The overall outcome for this group of Standards is judged to be Adequate. Anson Court is purpose built and service users live in safe and comfortable environment. There are good standards of hygiene, but the home must ensure that it always has access to suitable cleaning equipment. There are clear procedures in place to minimise the spread of infection. EVIDENCE: A tour was made of all the communal areas of the building. Several bedrooms, randomly selected, were inspected. Anson Court is suitable for its stated purpose and is comfortable, warm and generally well-maintained. There is a programme of routine maintenance in place. There are safe, well kept gardens to the rear of the property. Since the last inspection the front of the property has been tidied up. It was noted that the corridors are in need of repair and redecoration in some areas. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 17 All service users have their own en suite toilet and wash hand basin. There are sufficient bathing and toilet facilities in the home. All bedrooms provide at least 10 square metres of useable space. Where beds are placed against walls, the home have carried out a risk assessment to ensure that the service user does not need assistance from two carers on either side of the bed. Rooms are tastefully furnished and decorated. There is a lockable facility in each room. The majority of the rooms seen were in a good state of repair. There is a chipped toilet seat in Room 5 and Room 35 needs the wall repairing where the bed has knocked against it. The floor covering to the en suite toilet in Room 12 must be replaced. Some rooms (numbers notified to the Registered Manager) had an odour. The Manager explained that the home’s carpet shampoo was currently on loan to another home. By the time of the second day of the inspection the carpet cleaner was back at the home and this issue was being dealt with. All bedrooms are fitted with suitable locks. Service users are provided with keys unless their risk assessment suggests otherwise. The temperature of the water at outlets accessible to service users is tested each week and recorded. Several rooms were tested at the time of the inspection and there were none in excess of 43 degrees C. Apart from odours noted in bedrooms (above) the home was clean and fresh. There is a well-equipped laundry and a separate sluice facility. There are policies and procedures in place for the control of infection. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 18 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 and 30. The overall outcome for this group of Standards is judged to be Good. Anson Court is adequately staffed by well trained carers. There are robust recruitment procedures in place to protect the service users. New staff receive thorough induction training. EVIDENCE: At the time of the inspection there were 25 service users at the home and 2 were in Hospital. There were 5 care staff on the morning shift and 5 on the afternoon shift. The home employs sufficient cooking and housekeeping staff. At night there are 2 waking members of staff. The Registered Manager states that these staffing levels meet the needs of the current group of service users, but should dependency levels increase, staffing levels would be increased accordingly. The Manager’s hours are supernumerary, but she does spend time on care duties. At least 70 of the care staff group have achieved NVQ level 2 or above. Those that have not yet achieved the award are undergoing the training at present. The home does not employ Agency staff. The files of two newly appointed care workers were seen at the inspection in order to check compliance with recruitment requirements. Both files contained copies of 2 written references and a full employment history. There was evidence on files that both had been subject to satisfactory Criminal Records Bureau and POVA checks prior to being appointed. All staff are given copies of Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 19 the General Social Care Council Code of Conduct and sign to verify that they have received this. There is evidence on files that staff receive statements of their terms and conditions. There is a staff training and development programme in place. In addition to the mandatory health and safety training (see Standard 38), staff take part in Dementia Care training and Adult Protection training. The file of a newly appointed worker showed that she had received full induction training to Skills for Care specifications. Staff spoken to also confirmed that they had received a full induction. All staff receive a minimum of 3 days paid training a year. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 20 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 and 38. The overall outcome for this group of Standards is judged to be Good. The home is well managed by an experienced and well qualified Manager. There are systems in place to seek the views of service users and their relatives. The home needs to develop this further and publish an annual development plan. Service users’ monies are kept securely and proper records are maintained. The health and safety of service users and staff are protected by the home’s policies and procedures. Updated training is required in moving and handling. EVIDENCE: The Registered Manager has worked at the home for 8 years and has managed the home for 6. She holds the Registered Managers’ Award and NVQ4 Award, has a Diploma in Dementia Care Mapping and is an NVQ Assessor. She continues to enhance her skills and understanding through regular training. The Manager is very well respected by service users, their relatives and staff at the home. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 21 The views of service users are sought through service users’ meetings and through one to one conversations with the service users. Relatives’ Meetings are also held and their views are sought through questionnaires sent to them by the home on a regular basis. The results of these surveys are forwarded to the Commission. The home are recommended to also seek the views of visiting health and social care professionals. The home have yet to produce an Annual Development Plan. During the course of the visit service users and their visiting relatives gave their views of the home to the inspector. Service users’ financial affairs are mostly taken care of by their relatives. The home does, however, look after some personal allowances on behalf of service users. The Manager does not act as appointee for any of the service users. A random sample of the individual monies and accompanying records were seen at the inspection and all were in order. All monies are kept in appropriate safe keeping. From staff records seen and from conversations with care staff, there is evidence that regular training takes place in the key areas of moving and handling, fire safety, first aid, food hygiene and infection control. The home must ensure that that staff receive updated training in moving and handling, as some were seen to be handling inappropriately on the day of the inspection. Fire safety checks take place at the required intervals and the fire fighting equipment and alarm systems are regularly maintained. There is a satisfactory fire risk assessment in place. To ensure that all fire safety areas are regularly monitored the home have a Fire Procedures checklist in place. Up to date certificates were seen to verify the following: annual gas safety check, maintenance of the lift and hoists, legionella checks and the testing of electrical equipment. The temperature of water at outlets accessible to service users is taken each week and recorded. The home complies with COSHH regulations and has analyses of all products used. There are risk assessments in place for the whole building. It was noted that denture cleaner and bath crystals were in individual en suite bathrooms. The home is recommended to carry out a risk assessment in all these cases. If it is felt that these items present a risk to the service user, the items should be locked in the service user’s lockable drawer. The Accident Book was seen and was correctly completed. New staff receive induction training to Skills for Care specifications. The home have a regular health and safety check carried out by a professional body. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 22 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 2 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 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 2 Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 23 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 2 Standard OP7 OP9 Regulation 15(2) 13(2) Requirement Care plans must be updated following reviews to reflect changing needs. The temperature of the medicines’ refrigerator must be taken daily with a maximum/minimum thermometer and recorded. The home must ensure that its policy and procedure with regard to Adult Protection is in line with the local Social Services Policy and the Department of Health document “No Secrets”. The floor covering to the en suite toilet in Room 12 must be replaced. The home must, as far as possible, be kept free of offensive odours. Carpets in individual bedrooms must be regularly shampooed. (This was being dealt with on the second day of the inspection). The home must establish an annual development plan and forward a copy of this to the Commission. Timescale for action 30/09/06 30/09/06 3 OP18 12(1) 30/09/06 4 5 OP24 OP26 16(2)(c) 16(2)(k) 30/09/06 15/09/06 6 OP33 24(1) 31/10/06 Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 24 7 OP38 13(5) Staff must receive updated training in moving and handling. 30/09/06 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. 2. 3. 4. 5. 6. 7. Refer to Standard OP7 OP7 OP8 OP9 OP9 OP33 OP38 Good Practice Recommendations It is recommended that care plans be kept within the service users’ individual files and that these files are locked when not in use, to ensure confidentiality. It is recommended that care plans contain more information on the process of care, i.e. how the service user prefers the care to be given. It is recommended that the Registered Manager obtain an appropriate Nutritional Screening Tool for use when service users are admitted. It is recommended that the medication policy include a policy on covert medication. It is recommended that where service users keep creams in their rooms, these should be locked when not in use. It is recommended that the Registered Manager take part in the Advanced Dementia Mapping training. The Registered Manager is recommended to carry out a risk assessment in all those cases where service users keep denture cleaner or bath crystals in their rooms. If these items are considered to be a risk to the individual service user, they should be locked in the lockable drawer. Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Anson Court DS0000020842.V307816.R01.S.doc Version 5.2 Page 26 - 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!