Inspection on 27/02/07 for Acacia Court

This inspection was carried out on 27th February 2007.

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

Acacia Court 16/02/06

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 Donna Burnett Key Unannounced Inspection 27th February 2007 10:00 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.V331941.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. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acacia Court Address Crawshaw Hill Pudsey Leeds West Yorkshire LS28 7BW 0113 2559933 0113 239 4588 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.V331941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 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. At the present time, the home charges between £450-£500 per week. Additional charges are made for hairdressing, chiropody, newspapers and manicures. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit to the home, the registered manager completed and returned a questionnaire, which gave details about the home and its staff and was used to help plan the inspection. The home was provided with comment cards to distribute to people living at the home and their relatives. None were returned in time for the report. Four hours were spent preparing for the inspection, which was unannounced. One inspector spent a further six hours and forty-five minutes inspecting the home. Time was spent talking with people living at the home, the registered manager, members of staff and five visitors. Observations were made of the day-to-day running of the home to try and see what it was like to live there. A number of records were looked at to make sure that people were being properly and safely cared for. Two community nurses were also spoken with. What the service does well: What has improved since the last inspection? Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 6 Every person living at the home has a nutritional assessment to make sure that they get diet that they need. Most staff have attended basic food hygiene training so that they know how to handle food safely. Staff receive regular supervision from the manager who monitors their work and identifies training needs. Resident’s personal care needs are recorded in their individual files, which are kept private. 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. Acacia Court DS0000053221.V331941.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 Acacia Court DS0000053221.V331941.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. Staff are aware of, and are able to meet, the needs of each person new to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager carries out an assessment of need for anyone interested in coming to live at the home. Admissions are planned for and the staff informed in advance of the needs of each particular person. People who are thinking about moving to the home, and their families, can spend time at the home talking to other people who live there and meeting the staff. This allows them to make their own minds up about whether or not this is where they want to live. Information is made available to staff so they can understand the social, personal and emotional needs of people who live at the home, and know what Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 9 help to give. However, greater written detail would better inform staff about the specific needs of some people’. Standard 6 was not looked at as the home does not offer an intermediate care service. Acacia Court DS0000053221.V331941.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. People living at the home get the care they need and are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Every person living at the home has a ‘care plan’, which explains to staff what help to provide and how to give it. Observations of staff showed good awareness of resident’s care needs despite some lack of written information in the care plans. When someone is unable to sign their care plan to say they agree with its content, this should be recorded so that it is clear that they have at least been consulted with. Residents of the home are happy that they get the care they need. Two people commented that they had ‘never before been so well looked after’. One family member who was spoken to said that their relative had ‘never looked better’. People living at the home get good access to a variety of health care services and professionals. They get the help and care they need and are entitled to. A Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 11 district nurse visits the home most days and provides any nursing care that is required. Weight and diet are carefully monitored. Medication prescribed for people living at the home is stored safely. Staff can only administer medication once they have received relevant training and are considered to be competent. Records are kept of all medication, which comes into the home, so that there is a clear audit trail of how much medication should be on the premises at any given time. The manager and a senior member of staff both regularly check stock balances of medication to make sure that errors are not occurring. Staff quickly report and record any concerns they might have about a resident’s health so that prompt medical attention can be given. People living at the home are treated with respect and enjoy a great deal of privacy. They are addressed by the name that they prefer. All bedrooms are equipped with a telephone. The laundry service is very good and clothing is looked after well. A number of staff have attended training to enable them to care for people, with dignity, who are near the end of their life. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is excellent. People living at the home choose how they spend their time. They enjoy a high standard of food in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents choose whether or not to join in with things going on in the home. Many prefer to occupy their own time. Most days, some sort of social activity takes place. Residents can enjoy games of dominoes, bingo, sing-a-longs or visits from special interest groups. The home has a small selection of books and videos for anyone to use. A mobile library also visits and provides large print books for people with eyesight problems. A number of family members and visitors were seen at the home on the day of the inspection. Visitors say they feel welcome. The home has a number of small sitting areas where service users can enjoy peace and quiet, and greet their visitors, without having to go to their bedrooms. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 13 The manager has established good links with voluntary and advocacy services so that residents who do not have families, or who choose not to involve family members, can speak to someone not connected with the home. People living at the home choose where to take their meals but are encouraged to eat in the restaurant if possible. This promotes social interaction and allows staff to monitor dietary intake. Home cooked, wholesome meals are prepared using mainly fresh, local produce. Cakes and buns are all freshly baked on the premises. A recent survey carried out by the home showed 100 satisfaction with the choice, availability and quality of the food on offer. The catering staff are suitably experienced and ensure that the kitchen is kept clean and hygienic and that the food prepared is safe to eat. Residents who are able to do so safely, can make drinks in their own rooms with tea and coffee making facilities provided by the home. Residents have access to a dietician if there are concerns about nutrition and diet. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. People living at the home, and their representatives, know whom to contact if they have any concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is publicly displayed to all visitors to the home and a copy is also provided to each resident. The home receives very few complaints. People living at the home, and family members who were spoken to during the inspection, say they have nothing to complain about. They would not hesitate to speak to the manager or one of the senior carers if they had any issues or concerns. Resident’s meetings allow the opportunity for people living at the home to ‘have their say’. It is recommended that in future, the manager keeps a record of any commendations or concerns raised outside of such meetings. When suggestions are made, it should be clear that they are taken seriously and acted upon. The home’s policies and procedures protect residents from members of the public who may be unsuitable to work with vulnerable adults. Staff are trained to provide care in a safe way and residents confirm that they feel safe. There is evidence that staff attend training on the prevention of abuse. People living at the home describe the staff as ‘very kind’. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25 & 26. Quality in this outcome area is excellent. Residents live in a safe, comfortable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and provides a safe, comfortable environment for people to live in. The home is kept clean and tidy by a team of domestic staff who are praised by the residents. All areas of the home are wheelchair accessible. Inspection of a selection of records and certificates showed that the home is compliant with various health and safety laws. The grounds are pleasant and well kept. A number of bedrooms on the lower ground floor have direct access to the garden and patio areas. A recent survey conducted by the home found there to be 100 satisfaction with the cleanliness, décor and appearance of the home. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 16 There is sufficient indoor and outdoor communal space, for people living at the home, to have peace and quiet if they choose. The home does not accommodate people who smoke. The environment is light and airy which is particularly helpful for people with eyesight problems. Furnishings are comfortable and of a high standard. All bedrooms are en-suite with a bath, ensuring privacy for each resident. The home was free from offensive odours throughout the inspection. People living at the home and family members confirmed that this is always the case. The laundry is well run and organised in such a way so that soiled items do not come into contact with other laundry. Visitors are encouraged to use antibacterial hand wash on arrival to avoid bringing infection into the home. The home has good links with the infection control and environmental health nurses. Outbreaks of infection are reported to the relevant agencies without delay. Advise is sought and steps taken to safeguard and protect the residents of the home. Hot water temperatures are regulated to reduce the risk of scalding. There is an abundance of water thermometers throughout the home but there were no records of checks being carried out. There was, however, evidence that faulty thermostats are repaired and a random check during the inspection found the hot water temperatures to be within safe limits. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. The home employs enough, appropriately trained staff to be able to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at the home feel that although very busy, there is generally enough staff on duty to meet their needs. The home appeared to be sufficiently staffed on the day of the inspection and people were getting the help and care they required. The home does not use agency workers, which ensures consistency for the residents of the home. Members of staff spoken with during the inspection seem settled in their job and enjoy working at the home. This has a positive effect on service users in that they are cared for by a content staff team who have their best interests in mind. The home employs a high number of staff with recognised qualifications in care and who have undergone a great deal of training. The recruitment process promotes equal opportunities so that prospective employees are not discriminated against for their gender, race or disability. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 18 New employees are checked for their suitability to work with vulnerable adults. Induction training covers essential care skills such as people handling, fire awareness, food hygiene and infection control. A record is kept of all staff training. There has been recent training to make sure that staff are up to date in the skills and knowledge needed to care for residents of the home safely. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. The home is a well run, safe place to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is organised, competent and runs the home to meet the needs of the people who live there. She is currently undergoing further training related to the management of care homes. There is always a senior carer on duty to take responsibility for the running of the shift and the safety and well being of the residents. Residents, families and staff know who to got to if there is a problem and are very happy with the way in which the home is run. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 20 Meridian Healthcare Limited carries out an annual ‘client satisfaction survey’. All residents of the home are invited to express their satisfaction with the service. The findings of the most recent survey show 100 satisfaction with many aspects of the home including • • • • the the the the helpfulness of the management team professionalism of the staff helpfulness of the carers safety of the home. Comment cards are available for residents and visitors to complete at any time with suggestions and ideas about how the service can be improved for people living at the home. The reader is advised to refer to the Complaints and Protection section of the report for further information relating to the way in which the home seeks the views of people who use the service. Money left with the home for safekeeping is stored securely. Accurate records of all transactions are kept to prevent the risk of financial irregularities. Residents can have access to their money at any time. Staff are trained to move and handle residents safely. Training is provided at the home and updated regularly to take into account current safe working practices. Staff know what to do in the event of a fire and how to protect the people they care for. A selection of safety certificates and maintenance records were looked at which showed compliance with health and safety legislation. The manager makes sure that service users are cared for in a safe way by providing staff training, and facilities and equipment that is safe to use. There is restricted access to potentially hazardous areas of the home. Repairs are carried out as soon as is practically possible to keep the environment safe. The manager reports all incidents and accidents as required by law. Records are kept so that trends can be identified and steps taken to minimise the chances of similar incidents recurring. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X X X X 4 3 STAFFING Standard No Score 27 3 28 4 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 Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 22 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 Residents, or their representatives, should sign their own care plans to say that they have been consulted with and agree with the content. If a signature is not obtainable it should be recorded why. Timescale for action 27/05/07 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. Refer to Standard OP3 Good Practice Recommendations Information about the needs of prospective residents should be in more detail so that staff can refer to written information and not just rely on verbal feedback. Care plans should be more specific so that in an emergency, people not familiar with the content can use them. It is recommended that in future, the manager keeps a record of any commendations or concerns raised to show that they are taken seriously and acted upon. Checks on the temperature of hot water should be DS0000053221.V331941.R01.S.doc Version 5.2 Page 23 OP7 OP16 OP33 OP25 Acacia Court 5. OP31 recorded to prove that residents are not being put at risk of scalds. The manager should provide details in writing for the completion of the RMA NVQ level 4. Acacia Court DS0000053221.V331941.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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