Inspection on 16/02/06 for Acacia Court

This inspection was carried out on 16th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Acacia Court 27/02/07

Acacia Court 04/10/05

Acacia Court 05/01/05

Acacia Court 25/08/04

Acacia Court 10/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Acacia Court Crawshaw Hill Pudsey Leeds West Yorkshire LS28 7BW Lead Inspector Susan Knox Announced Inspection 16th February 2006 09:15 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 Acacia Court DS0000053221.V271932.R02.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. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acacia Court Address Crawshaw Hill Pudsey Leeds West Yorkshire LS28 7BW 0113 2559933 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) Meridian Healthcare Ltd Mrs Tina Davies Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Acacia Court provides accommodation for forty older people. It is a purpose built property and aims to offer a style of accommodation similar to that of a hotel. The home is conveniently located in the centre of Pudsey. There are a range of local amenities and facilities in the vicinity, including shops, pubs and public transport. All the bedrooms are single occupancy and have en-suite facilities. There is a large dining area and various communal lounges throughout the building, on both floors. The home operates a no smoking policy. Parking space is available and there is level access into the home. Accommodation is provided on three floors and a passenger lift ensures easy access to all. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by one inspector between 9.15 am and 3.15pm. Time was spent talking in depth to nine service users, four staff and observing practice. Records were checked including duty rotas; service user’s care records, staff and fire records. Some bedrooms and other areas were checked. A pre inspection questionnaire was sent to the home to be completed and also comments cards for distribution to service users and relatives. None were returned in time for the report. Service users and staff spoke well about the service provided in the home What the service does well: What has improved since the last inspection? What they could do better: Staff should attend training about nutrition and the elderly. Staff supervision has to be held six times a year and new staff inducted within three months. Care planning is too generalised and does not fully address individual needs. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 6 Service users and staff meetings should be held more regularly. Notices should not be displayed in bedrooms that include personal care details about individuals. 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. Acacia Court DS0000053221.V271932.R02.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 Acacia Court DS0000053221.V271932.R02.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): 1. Detailed written information is available about the home to enable people to make informed decisions. EVIDENCE: The manager said that the home’s brochure and information booklet is given to prospective service users and/or relatives. The scale of charges relates to the size of the room and this would be discussed at the time of the assessment. A service user confirmed that she had been given an information booklet. This home does not provide intermediate care. Acacia Court DS0000053221.V271932.R02.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, 9, 10. Care plans need further work in order to focus on individual needs. Service users were pleased with the care provided. The procedures for administrating medication ensures that service users are protected other than one issue that is to be addressed. The majority of working practices in the home do protect service users privacy. Care is needed to ensure that displayed notices do not compromise this. EVIDENCE: Three sets of care documentation were reviewed. All had care planning in place and were evaluated every month as required. Service users and/or relatives are involved and this was confirmed in their signatures on care plans. Risk assessments relating to moving and handling were up to date. In relation to one other service user the manager was advised to introduce a nutritional risk assessment. This would ensure whether dietary interventions were required. The care plans seen were too generalised and did not fully address individual needs. For example, catheter care did not address the concerns about Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 10 bypassing or blockage of the equipment. Staff were able to describe the actions that they took but this was not recorded in the care plan. Service users were pleased with the care provided by staff. One said they were particularly effective during a recent outbreak when service users had to be confined to bedrooms for a period in order to comply with advice from an Infection Control officer. The home administers medication via a Monitored Dosage System (MDS). A Policy and Procedure document was available in the drug room. Staff confirmed during discussions that training in the administration of medication had been undertaken. No homely medication is kept by the home. Stock medication and currently used medication are kept separately as required. A medication fridge is in use for topical medication requiring cool storage. A random count of medication showed that a paper trail could be followed and accounted for the number of tablets brought into and administered in the home. The manager was advised that the record of medication brought in other than via the MDS system such as antibiotics, should be improved. The date and amount should be recorded. Service users said their privacy was respected. During the inspection staff were seen to knock on doors before entering. A number of notices were displayed in bedrooms that could affect their privacy, as these were reminders to staff about personal care tasks. In one room the notices were acceptable as the aim was to re orientate the service user about daily tasks. Discussed with the manager was the view that excessive notices could give the impression of an institution and that personal information about care should not be displayed. Acacia Court DS0000053221.V271932.R02.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): 13, 14 & 15. Visitors are welcomed into the home and can see their relatives in private. Choice in daily activities including meals is readily available although service users need to be reminded at times. Meals are provided in comfortable surroundings and individual needs are met. A variety of meals are on offer and fresh food is readily available. This good practice could be promoted further with nutritional assessments and staff training on nutrition. EVIDENCE: Service users confirmed their relatives were made welcome by staff when they visited. The majority of visitors are seen in the privacy of the service user’s rooms. Although the main lounge is a busy room there are three other smaller lounges where visitors can be received. The home is in the middle of town and very convenient for the nearby facilities such as the Health Centre and shops. Some leave the home independently or in the company of staff or relatives in order to access these facilities. In this way they are able to make choices. The majority of service users were pleased with the choice that is offered in daily living activities such as bath times. They also confirmed that bed times Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 12 were entirely their own choice and some said they had a choice of taking breakfast in their rooms. A few said they had to go to the dining room for breakfast. The manager confirmed that this option was available to all service users. Discussions were held about reinforcing this information at a service user meeting. Meals are taken in the restaurant; this is an area that is screened off from the lounge. There is a servery linking the dining room and the kitchen. Service users dine at tables laid for four people. Tables were well laid with appropriate crockery and cutlery. The dining room provides a very pleasant atmosphere that enables social interaction. Comments about meals did vary from ‘gorgeous food’ to ‘foods all right’. The majority of the service users spoke well about the quality of the meals. The manager advised that a review of menus is undertaken with service users at their meetings. In order to ensure that likes and dislikes are fully understood it is recommended that the cook meet with new service users shortly after admission. The lunchtime menu provides a choice of two hot meals and three puddings. The evening meal menu offers two hot choices, salad, four different types of sandwiches and five types of pudding including yoghurts and ice cream. Discussions with the cook showed she had a good understanding of individual needs. The kitchen was clean and documentation relating to food hygiene was up to date. Deliveries of fresh vegetables and fruit were seen in the kitchen and the cook confirmed that a fruit bowl is placed in the lounge for service users. Some also visit the kitchen to request fruit. Discussions were held with the manager and the cook about those who may regularly refuse meals or lose weight. Both confirmed that supplementary meals would be given and a dietician contacted for advice. In order to continue to meet individual needs it is recommended that a nutritional risk assessment is included in care planning to enable early identification of concerns. Nutritional assessments should be used where there is on going refusal of a balanced diet or weight loss for no known reason. In addition the cook and the manager should attend training about nutrition and elderly people. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 13 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 Information is made available so that people know the complaint’s procedure. Service users would speak to staff if they had concerns. EVIDENCE: A complaints procedure is displayed in the entrance to the home. It is also included in the Statement of Purpose. The manager advised that no formal complaints have been made. Meridian Care Ltd has appointed a responsible person to visit the home and submit monthly reports about these visits to the company; to the manager and also to CSCI. These reports also reflect that no complaints have been made. In discussing whom they would approach if they had concerns, service users said they would have no problems in approaching management and staff. Many named the staff they would speak to. It was also confirmed that service user’s concerns are raised during their meetings. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 14 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): 19-21, 23-26. The environment ensures that service users are very comfortable in their surroundings. The building is very well maintained. Facilities are regularly improved. Cleanliness and odour control are maintained to very high standards. Infection control procedures are good but could be improved further in order to protect the service users. EVIDENCE: A major refurbishment of the home has recently been carried out to a high standard. This purpose built care home provides accommodation on three floors. There is level access into and throughout the building and a passenger lift. Some bedrooms located on the lower floor have direct access to the garden. One service user described looking forward to the warmer months when she could sit outside to enjoy the better weather. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 15 Communal areas are located in a number of places throughout the home. The main lounge includes the dining room (known as the restaurant). All these rooms are furnished to a very high standard. Three sizes of bedrooms are available. All rooms have been refurnished. One service user confirmed that she had been involved in the choice of colours for redecoration. Many service users have items of own furniture that has been retained. They said they were very comfortable in their rooms. All bedrooms are single occupancy and have en suite facilities. Door keys are provided to ensure privacy and many service users make use of the keys. Lockable facilities are also provided for personal possessions. Heating can be controlled in individual bedrooms and there is natural ventilation. In two of the bedrooms it was noted that pipes were making a knocking sound when the hot water was used. This was referred to the manager for action. In addition to ensuite facilities, there are a number of WC’s and communal bathrooms located throughout the building. A sit down shower has been installed since the last inspection. Unfortunately, there is a step to access the area due to problems with plumbing. Service users were pleased with the cleanliness of the home and said that staff worked hard to maintain standards. All areas were clean with no malodour apart from one bedroom identified to the manager. Some containers of cream, bars of soap and terry towels were noted in the communal bathroom. All need to be removed in accordance with infection control. If service users wish to use these items in communal areas these should be replaced in bedrooms afterwards. Paper towels were available but no liquid soap. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 16 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, 29, 30. Staffing levels meet the needs of the service users. Good recruitment practices ensures the safety of service users. Staff are provided with the opportunity to attend a variety of training courses in order to meet individual needs. For the same reason new staff must complete their inductions within the required time scale. EVIDENCE: The staff roster for the week of the inspection was seen. The staff team comprises of the manager, senior care staff, care and ancillary staff. The manager confirmed that staffing levels had increased since the last inspection. Staff confirmed during discussions that although very busy at times staffing levels had improved. Two staff files were checked. These were well kept with evidence of identity checks; Criminal Record Bureau (CRB) checks and two references obtained. Job descriptions and terms and conditions were available. CRB records are stored separately and the manager confirmed these are obtained as required before staff start work. Staff records include training courses attended. All new staff complete an induction programme. This was confirmed in discussions with staff. One induction/foundation workbook for a new member of staff showed that the induction had not been completed and the member of staff was now into her Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 17 fourth month. Inductions should be completed within six weeks of employment and foundation training completed in a six-month period. From the records and in discussions with staff it was clear that training is regularly organised for staff. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 18 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, 35-37. The home is well managed but the RMA and NVQ level 4 has to be achieved. The home has gone through a very busy period that was well managed as seen in up to date records. In order to ensure that high standards are maintained staff supervision and regular meetings must be held. The health and safety of people in the home is promoted. EVIDENCE: Ms Tina Davies is the registered manager of the home. She advised that she has decided to enrol with another agency in order to achieve the Registered Manager’s Award (RMA) and NVQ level 4. This is a requirement. She was able to provide evidence that she has completed a number of modules with her present agency. She was advised to submit in writing an estimated date for completion of this training. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 19 Due to the recent busy period of extensive refurbishment and viral outbreak, supervision of care staff has stopped. This must be carried out at least six times a year. In addition regular service user and staff meetings have not been held. These need to be restarted. Feedback from service users and staff indicates that the manager is good and deals with any concerns. The records seen were up to date, well documented and securely kept. The care plans clearly show the service users right to access personal records. Some personal allowances are kept for safekeeping. The manager confirmed that records are kept of all transactions. Health and safety records such as those relating to fire were well kept and up to date. The manager was advised to record the visual check of emergency lights. These are carried out when fire alarms are tested. Fire extinguishers are tested the last date April 2004. Fire training is carried out monthly the record includes the names of those staff attending. Eight staff have recently completed Food Hygiene training and others are booked to attend. Three staff are due to attend Moving and Handling training and others are to attend Health and Safety. Accident reports were available and were satisfactory. The manager confirmed that she is to reintroduce the monthly auditing of accidents in the home. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 4 4 4 X 4 4 4 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 3 X Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Requirement The registered manager must ensure that care plans address the individual needs of service users. Include nutritional assessments. The registered manager must ensure that the number/amount of all medication brought into the home is recorded with the date of delivery. The registered manager must ensure that notices displayed do not include personal care details. The registered manager must ensure that staff attend training in nutrition. The registered manager to ensure that personal creams, soap and towels are not left in communal bathrooms. The registered manager must ensure that the visual check of emergency lights is recorded. Timescale for action 31/03/06 2 OP9 13 16/02/06 3 4 5 OP10 OP15 OP26 12 16 13 16/02/06 31/03/06 16/02/06 6 OP38 38 16/02/06 Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 22 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 Refer to Standard OP32 OP31 Good Practice Recommendations Rearrange meetings for service users and staff. Provide details in writing for the completion of the RMA NVQ level 4. Acacia Court DS0000053221.V271932.R02.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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