Care Home: Anbridge Care Home

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What the care home does well The manager obtains a detailed assessment of need prior to people being admitted ensuring their need can be met. From this a care plan is developed which incorporates people`s preferences in their daily life. For example, sleep patterns with preferred bedtimes and how many pillows required. In one instance, it was recorded that the person prefers to sleep with the light on. One person said, `I sleep well at night, staff make sure I am okay when I call them.` It is the area of daily life which the home excels in providing structure and fulfilment based on individual and group work through the employment of a full time activity co-ordinator. The management and staff team strive to engage people in daily living task that they have used throughout their lives. For example, ironing (within a risk assessment framework), cooking and cleaning. Some of these practices were observed on the day of inspection and promoted ownership and a sense of community. One person said, `Staff are really good here, we have a bit of a laugh and I have made some good friends.` One person said, `we have lots of choices of food and we get a party tea at birthdays. Staff come round and ask what we want every morning.` Another said, `They always ask what you would like or give you something else if you prefer.` A substantial amount of building work and refurbishment is taking place in the home at present. However, hygiene standards were maintained and people told us they were kept informed of the developments and were looking forward to new facilities. A newsletter is produced "Anbridge Exciting Times" which keeps relatives and people in the home informed of future activities and developments in the home. Regular consultation takes place via the activity co-ordinator and the home`s quality assurance systems. There was evidence that staff received training in line with people`s needs. What has improved since the last inspection? There was evidence to show that risk assessments and reviews took place. However, the content of the file and documentation was difficult to follow. The manager had recognised this, stating on their Annual Quality Assurance Assessment and had started to streamline documentation making information easily accessible to staff.One good practice recommendation made on the last inspection was to review the timing of meals and suppers in order to reduce the length of time between suppers and breakfasts. The manager had done this through consultation with people in the home. Another good practice recommendation related to staffing levels over a weekend period need to be monitored to ensure people received the care needed. The manager has increased ancillary hours to relieve staff of domestic duties. CARE HOMES FOR OLDER PEOPLE Anbridge Care Home 1 Herbert St Watersheddings Oldham Lancashire OL4 2QU Lead Inspector Sandra Buckley Unannounced Inspection 18th August 2008 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 Anbridge Care Home DS0000062410.V369372.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. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Anbridge Care Home Address 1 Herbert St Watersheddings Oldham Lancashire OL4 2QU 0161 665 2232 F/P 0161 665 2232 anbridgecarehome@tiscali.co.uk 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 Sally Anne Jones Mr Charles Paul Jones Mr Charles Paul Jones Care Home 20 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (14), Physical disability over 65 years of age (1), Sensory Impairment over 65 years of age (1) Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 20 service users to include: *up to 5 service users in the category of DE(E) (Dementia over 65 years of age); *up to 1 service user in the category of PD(E) (Physical disability over 65 years of age); *up to 14 service users in the category of OP (old age not falling within any other category); *up to 1 named service user in the category of SI(E) (Sensory impairment over 65 years of age); *up to 1 named service user in the category of MD(E) (Mental disorder, excluding learning disabilities over 65 years of age). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 18th September 2007 2. Date of last inspection Brief Description of the Service: Anbridge is a privately owned care home registered to accommodate 20 people. The home is situated in the Watersheddings area of Oldham and is within easy reach of shops, a park and other community facilities. The building is a detached property with pleasant gardens to the front and rear, and car parking space to the side. Accommodation for service users is provided on the ground, first and second floors of the building. A passenger lift has been installed between these floors and ramped access has been provided externally. There are 16 single bedrooms, 11 of which have en-suite toilet facilities (four rooms also have an en-suite shower), and two double bedrooms, one of which has en-suite toilet facilities. Fees charged by the home are £350 to £360. Anbridge Care Home DS0000062410.V369372.R01.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 2 stars. This means the people who use this service experience good quality outcomes. This was a key inspection that included a site visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, including observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned from residents and their relatives are also included in this report The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. The manager had completed this in full and comparisons were made with this document at the time of inspection. On this inspection the outcomes for people in the home did reflect that indicated by the manager in the Annual Quality Assurance Assessment especially in relation to daily life, personal care and protection. However, the manager had recognised what improvements could be made and was taking steps to address the issues. There has been one adult protection issue in relation to care practices since the last inspection, which on investigation was not founded. The Commission for Social Care Inspection is satisfied that safeguarding adults procedure was followed. The manager stated on their Annual Quality Assurance Assessment that four complaints had been received out of which one was upheld. The Commission for Social Care Inspection had not received any complaints since the last inspection. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There was evidence to show that risk assessments and reviews took place. However, the content of the file and documentation was difficult to follow. The manager had recognised this, stating on their Annual Quality Assurance Assessment and had started to streamline documentation making information easily accessible to staff. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 7 One good practice recommendation made on the last inspection was to review the timing of meals and suppers in order to reduce the length of time between suppers and breakfasts. The manager had done this through consultation with people in the home. Another good practice recommendation related to staffing levels over a weekend period need to be monitored to ensure people received the care needed. The manager has increased ancillary hours to relieve staff of domestic duties. 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. The summary of this inspection report can be made available in other formats on request. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. A professional assessment of need is obtained is obtained prior to people entering the home ensuring their needs can be met. EVIDENCE: Three case files were examined and found to contain a professional assessment of need. The Annual Quality Assurance Assessment completed by the manager also stated “We continue to carry out a full and detailed assessment of all prospective residents’ care needs to ensure we are the right home for them”. The manager recognised areas that could be improved, saying in the “could do better” section of this document that they should continue to try and attract people from all ethnic groups. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 10 There was evidence that the statement of purpose and service user guide had recently been upgraded to reflect developments in the home. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People’s needs are met through appropriate care planning linked to their assessment and staff training is provided in line with people’s needs. EVIDENCE: We looked at three care plans that were linked to people’s assessment of need and found that information from the assessment had been transferred appropriately, providing sufficient information to staff on which to carry out their duties. Two staff questionnaires were received; one said ‘When it is necessary for me to know, I have access to care plans as required.’ Another said ‘they always received information about people’s needs.’ Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 12 There was evidence to show that risk assessments and reviews took place. However, the content of the file and documentation was difficult to follow through in some instances and may lead to staff not accessing all information required. The manager had recognised this, stating on their Annual Quality Assurance Assessment ‘although are care plans are very detailed and informative, it has become apparent that it is not always easy to allocate information from the care plan simply and quickly. We have therefore thought very carefully on how we can improve on this and have come up with the following changes. Our present care plans have systematically cleared of all necessary information and restored to their original format. Also, we are adapting an improved care plan booklet which should allow us to be more flexible in the way we record and store information.’ People’s daily life preferences were also recognised in care plans. For example, sleep patterns with preferred bedtimes and how many pillows required. In one instance, it was recorded that the person prefers to sleep with the light on. One person said, ‘I sleep well at night, staff make sure I am okay when I call them.’ There was evidence that staff had just completed a refresher course in moving and handling and staff training was given a high profile. We observe staff using safe working practices. People had access to health care professionals. One person said, ‘I clean my own teeth and have not been here long enough for a visit from the dentist, but have been told I can have one.’ Medication was administered, recorded and stored appropriately. Examination of accident recording found that 36 accidents had occurred between 4th June 2008 and 19th August 2008. Of these, 21 did not state whether an injury had occurred or not. One person had been to the falls prevention nurse and another to Accident and Emergency. The Commission for Social Care Inspection had not been notified of any of these occurrences. The manager is required under Regulation 37 of the Care Standards Act 2000 to inform the Commission for Social Care Inspection of any adverse incidents in the home, which may affect people living there. Sufficient equipment was in the home to promote independent people, for example, standing hoist, staff hoist and grab rails. Outcomes for people in the home remain positive, all looked well presented, clean and tidy. Anbridge Care Home DS0000062410.V369372.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. People’s individual needs and choices are met in daily routines, promoting a sense of fulfilment. EVIDENCE: This area of daily life is where the home excels in looking at individual needs linked to care planning and striving to engage people in daily living skills that they used throughout their lives. They employ a full-time activity co-ordinator who provides group and individual activities, enabling those people who may be unable to join in through frailty or illness one to one attention. For example, beauty therapy, hand massage, recognising the importance of touch. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 14 A notice board is on display in the dining room. This is in picture format and portrays the daily events. A wide range of activities is on offer, which are flexible and takes into consideration people’s frailty and volatile health problems. The latter being stated on the Annual Quality Assurance Assessment completed by the manager, which also stated ‘We endeavour not to overstretch an individual in a way which would leave them feeling incapable or helpless.’ Two mornings and two afternoons a week are set aside for outside activities in small groups by way of the home’s adapted vehicle. A digital photo frame is on display in reception, which enables them to show up to date photos of different events. Some people in the home wish to continue chores they did whilst in their own homes, for example, ironing (within a risk assessment framework), cooking and cleaning. Some of these practices were observed on the day of inspection and promoted ownership and a sense of community. One person said, ‘Staff are really good here, we have a bit of a laugh and I have made some good friends.’ Through discussions with people it was identified that some people had been on a trip to Hollingworth Lake which they enjoyed; they particularly liked the activity co-ordinator doing monologues for discussion, the last one being one of Stanley Holloway. People also talked about outside entertainers coming in which they also enjoyed. We dined with people in the home; the menu consisted of meat pie or salmon in sauce with apple crumble and custard for sweet. Choices were also available. One person said, ‘We have lots of choices of food and we get a party tea at birthdays. Staff come round and ask what we want every morning.’ Another said, ‘They always ask what you would like or give you something else if you prefer.’ One good practice recommendation made on the last inspection was to review the timing of meals and suppers in order to reduce the length of time between suppers and breakfasts. The manager had done this through consultation with people in the home. Whilst dining with people, they discussed the ongoing building work and the fact they were kept informed and were looking forward to the completion and better facilities. Tables were set attractively, appropriate age-related music was playing and fresh fruit was on each table. People said fresh fruit was always available. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 15 The manager stated that a member of the clergy visits every Sunday to offer communion and usually five people take this opportunity. People are able to have their hair done weekly if they wish and all were well presented with some people wearing jewellery of their choice. The manager had stated on the Annual Quality Assurance Assessment that comments received from consultations with relatives, showed that they were not always aware of what was going on in the home. From this, a monthly publication called ‘Ambridge Exciting Times’ has been produced which details events taking place, trips out, birthday parties and general day to day information. A monthly review in brief is also produced and sent out the relatives who find visiting on a regular basis difficult. Anbridge Care Home DS0000062410.V369372.R01.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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People are comfortable in raising concerns they may have and are protected through staff training in the protection of vulnerable adults. EVIDENCE: The manager stated on the Annual Quality Assurance Assessment that four complaints had been received, out of which one had been upheld. All complaints were recorded and included the process and action taken. The Commission for Social Care Inspection had not received any complaints since the last inspection. The complaints procedure is clearly displayed in the home. Each staff had a training file, which shows certificates for protection of vulnerable adults training. At interview staff demonstrated a good knowledge of how abuse may present and their role in preventing any such issues. During interviews with people in the home, one person said: ‘I would see the manager if I weren’t happy but everything is okay’, another person said, ‘I have no complaints but would complain if I had to. I do feel safe living here.’ Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 17 The Annual Quality Assurance Assessment stated “Our survey questionnaires for both residents and relatives show that they feel if they were to complain, their complaint would be listened to and acted upon appropriately. For those who have complained, they felt that they had been listened to and the complaint was resolved effectively.” There has been one adult protection issue in relation to care practices since the last inspection, which on investigation was not founded. The Commission for Social Care Inspection is satisfied that safeguarding adults procedure was followed. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People in the home live in a clean and odour free environment and are kept informed of building developments and encouraged to personalise their rooms providing a feeling of ownership. EVIDENCE: The home was undergoing considerable refurbishment through extension of the property. This extension would eliminate the two-shared rooms and add additional en-suites. There are also plans for a new bathroom/wet room upstairs and a toilet situated close to the lounge area making easier access for the residents. There is a small lounge at the front of the building that is also being extended. Risk assessments have been completed on each room in relation to the impact of the work and any fire risk. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 19 At the time of this visit, officers from the Fire Service were visiting the home and raised a number of concerns on fire safety. The manager was advised of the work that was required and the manager acted upon this immediately. Further discussions were taking place with the fire officers for the remainder of the work and the manager was advised to contact specialist fire services. The manager had recognised many issues and produced a refurbishment plan, which was prioritised. For example, corridor carpets were in need of replacement and will be replaced on completion of the building work. The home offers a quiet sitting area in the reception. We looked at a selection of people’s bedrooms and found that some rooms had been upgraded and others formed part of the new refurbishment plan. Despite the continued building work, standards of hygiene were maintained. People in the home said they were kept informed of ongoing developments. One person said: ‘We are kept informed of what is going on, it will be nice to have a larger lounge.’ The home’s Annual Quality Assurance Assessment in the section ‘could do better’ stated: “At present our housekeeper works Monday, Tuesday, Thursday and Friday. We feel it would be very beneficial to employ a domestic assistant to cover the days that she does not work so that we would and we are actively in the process of doing this.” A selection of rooms were viewed and found to be homely and personalised. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Recruitment procedures were robust and staff training provided in line with people’s needs. EVIDENCE: Examination of the staff duty rota showed that for 20 residents the manager worked from 8.30 till 5. Care staff shifts include 7.30 to 3 – three care staff. Then up to 5pm three staff, after which the number drops to two staff. Two cooks are employed 8 to 5 and two night staff are on duty. In addition to this, there is also a full-time activity co-ordinator. Over the weekend period, these numbers reduce to two staff plus ancillary staff. On the previous inspection, the manager was asked to keep these staffing levels under review, and to increase in line with people’s dependency levels. Since the last inspection, weekend ancillary staff have been employed to ensure staff only have caring duties to carry out. A number of people in the home were semi-independent and required minimum assistance or prompts from staff. However, staffing levels need to be monitored over the weekend period to ensure people’s needs are met Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 21 Staff training was given a high profile and certificates were seen of courses completed. These included health and safety awareness, dementia care, moving and handling, POVA and first aid, with 50 of staff have obtained NVQ 2 and 40 are working towards this. At interview, staff demonstrated a good awareness of people’s needs, saying they had time to read care plans. Examination of recruitment fields found that all appropriate Criminal Record Bureau checks had been carried out and two references obtained prior to commencement of work. Comments received from staff questionnaires were “I could not work here without initial checks. My induction consisted of given lots of time to read notes and become familiar with residents before I began.” Also: “I am always given training relevant to the role.” Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. An open and inclusive management style ensures staff and residents’ views are obtained. EVIDENCE: The manager is a qualified nurse and has a number of years’ experience in care and work with older people. They continue their professional development by attending refresher course and in-house training. There was evidence that the manager operates an open and inclusive approach through staff and resident meetings, and quality assurance systems. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 23 The last staff meeting minutes on 12th June 2008 listed the agenda as: discussion on statutory training, e.g., moving and handling and fire safety. Also the need for people who receive soft diets to be given more choice. Staff were also encouraged to discuss individual people that they may have concerns about and behaviour management. The activity co-ordinator consults with people in the home in both group and individual level, depending on their capabilities. There was evidence that people were encouraged to participate in daily life in the home to the level of their capabilities within a risk assessment framework. People were asked to discuss their views on developments, especially the building work and, in particular, what type of garden and plants they would like. Staff at interview said they received regular supervision from the manager. Health and safety checks where carried out on equipment in the home and fire alarm checks were undertaken weekly. On the previous inspection a good practice recommendation was made in relation to updating the emergency policy procedure, especially in relation to accidents and in what circumstances medical assistance should be sought. The manager had updated their policy and procedure to reflect this information. We looked at record keeping in relation to people’s finances held at the home and found these to be recorded correctly with outgoing and incoming recorded. Monies held matched the recorded balance. Accident recording also needs to be improved to provide details of injuries sustained with the Commission for Social Care Inspection being informed under Regulation 37 of the Care Standards Act 2000. The Quality Assurance system questionnaires were last sent out to the residents and their relatives in April 2008, with the manager taking action on comments made, for example, lack of information on activities which has resulted in a brief newsletter. Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 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 3 X 3 X 3 X X 3 Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP8 Good Practice Recommendations Ensure that accidents are recorded in full stating what injuries have occurred, if any, and report any adverse incidents to the Commission for Social Care Inspection under Regulation 37 of the Care standards Act 2000. Ensure that the home complies with fire regulations while building is in process. Keep staffing levels over a weekend period under review, in line with people’s dependency levels. 2 3 OP19 OP27 Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Area Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Anbridge Care Home DS0000062410.V369372.R01.S.doc Version 5.2 Page 27 - 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. 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