Inspection on 04/10/05 for Acacia Court

This inspection was carried out on 4th October 2005.

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 27/02/07

Acacia Court 16/02/06

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 LS28 7BW Lead Inspector Susan Knox Unannounced 06 September - 04 October 2005 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 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 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Acacia Court Address Crawshaw Hill Pudsey Leeds LS28 7BW 0113 2559933 Telephone number Fax number Email 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 T Davies Care Home 40 Category(ies) of Old Age (40) registration, with number of places Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5 January 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 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector between 9.30 am and 3.30pm. Time was spent talking to residents, staff and observing practice. Records including duty rotas, service user care records; recruitment records and staff training records were seen. Some bedrooms and other areas were checked. A number of comment cards were left to be given out to service users and relatives and then returned to the CSCI. Feedback was to the registered manager Ms T Davies and her line manager Ms M Bennet. Requirements and recommendations from this inspection are included at the end of the report. What the service does well: What has improved since the last inspection? What they could do better: Management must maintain care staffing levels to the minimum or above. This very busy staff team do not have the time to spend any length of time with service users this would be eased by the recruitment of another member of care staff. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 6 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 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 standard(s) 2-5 Detailed information is available about the home. Service users and their families are given an opportunity to look round before deciding whether to move in. Terms and conditions/contracts are available. EVIDENCE: A service user said that written information about the home was made available to their relative before admission. The local authority contracts were available for those who are funded. For those self-funding the home has provided contracts. This document includes the number of the room occupied and was signed by the service user or relative. Service users and a relative did confirm that they were encouraged to visit the home and stay for a meal before making a decision to move in. This was also confirmed in discussions with staff. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 standard(s) 7, 8, 10, 11. Care planning and health care is good and staff are given direction about how to meet individual needs. Service users are treated with respect and their privacy is maintained. Where incidents arise they are managed successfully. The last wishes of service users are respected. EVIDENCE: Three care plans were checked. Care plans were in place for all three and followed on from the initial assessment. Care planning was good and reflected the independence of the service users. Risk assessments were in place such as for those with moving and handling needs. Signatures of service users or relatives were available in documentation indicating involvement and agreement to care plans. Or in one case an explanation given for not being involved. Evaluation of planning was carried out monthly. On the day of the inspection three service users were being escorted to visit the health centre to attend appointments with their GP. The staff would Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 10 accompany the service user in to see the GP only by invitation. One service user discussed her health needs and confirmed staff were meeting these. The records showed the involvement of doctors, district nurses and health specialists. Weights were monitored. New staff are inducted into the home and this includes the home’s principles of care about dignity and privacy. During discussions with service users about the degree of help required with personal care it was clear that staff did give respect and maintained privacy. One issue discussed by a service user about an incident where a member of staff failed to give respect had been dealt with by management to the service user’s satisfaction. From discussions with staff it was clear that terminal care and the last wishes of service users are given priority. A clear account was given about an instance where last wishes made known to the staff were carried out. Staff would continue to provide care if possible in the service user’s own room. The district nurse would be asked to help with any additional equipment required and contacted for advice about pain control. Care documentation provided details about last wishes. The family would be encouraged to come and go as they wished. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 standard(s) 12, 14. Activities are provided for service users but additional staff would enable the staff team to give more choice and more one to one activity. The home provides the opportunity for service users to express choice in dayto-day routines and refurbishment. Health and safety directives may infringe on choice. EVIDENCE: Activities are held in the lounge although there is an activity room this has not been used as regularly as in the past. Staff said that bingo dominos and cards were popular. It was said that a small group of service users enjoy organised activities but the remainder are uninterested. Motivation classes are held every month and includes armchair exercises. Staff said there is little time to spend with service users although in depth discussions happen when carrying out personal care tasks. Service users confirmed that they had recently attended a meeting where they were able to express any concerns to management. Routines are flexible and this was confirmed during discussions with both service users and staff. Service users confirmed that they were given the choice to have breakfast served in their rooms. One had requested that all meals be served in her room for a while and this was done. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 12 Bedrooms are due to be redecorated and since the last inspection service users have been involved in choosing colours from a selection of four. This is good practice. Discussions were held about the notices displayed on bathroom doors to keep ’closed and locked’. Management advised that this was on instruction from Meridian Care’s health and safety advisor for the protection of service users. Although this does not create major difficulties as service users have en suite facilities this is an institutionalised practice and management quite rightly are challenging this policy. Food and mealtimes were not inspected at this visit although some service users raised concerns about the meals. However, the same number said the food was good. One family said they had stayed and had meals with their relative and the food was good. The concerns were expressed at the service users meeting and discussions were being held by management to resolve this. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 standard(s) 16, 18. Service users are able to speak to management and staff about their concerns. Procedures are in place for dealing with possible abuse. Regular discussions help staff understand what action to take in order to protect service users. EVIDENCE: A detailed complaints procedure is available and included in the Statement of Purpose. A notice is prominently displayed to this effect in the entrance. The manager is aware that any complaints received must be investigated and records kept. She advised that none have been made. Service users had no problems in approaching management and staff to discuss their concerns. The local authority guidance on procedures in case of abuse is available in the office. The manager advised that she has attended Adult Protection and Abuse training. She is currently cascading this to the staff group in training sessions. Staff confirmed this. The organisation provides policies and procedures relating to Adult Protection and Dealing with Aggression. This is also included in new staff’s induction to the home and evidenced in induction records. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 standard(s) 19, 26. A clean and pleasant environment is provided for service users to live in. The provider ensures that refurbishment is on going. This is carried out to a very high standard and gives very comfortable accommodation for service users. EVIDENCE: This purpose built care home provides accommodation on three floors. There is level access into and throughout the building and a passenger lift. The building and gardens are very well maintained. A major refurbishment of the home has been carried out to a high standard. This is on going and work is due to start on the refurbishment of bedrooms. It was agreed during the inspection that the smallest lounge could be used temporarily as a bedroom providing the local fire officer was happy with the arrangements and call alarms were in place. Service users will vacate their room overnight only in order to allow ventilation of paint smells. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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). This room was one of the first areas to be refurbished. Three sizes of bedrooms are available and rooms will be graded according to size and refurbished accordingly. New beds, carpets, lights, bedding and furniture will be provided to some degree in the bedrooms. All bedrooms have en suite facilities. Service users said they were very comfortable in their rooms and appreciated the quality of the furnishings. In addition, there are a number of WC’s and communal bathrooms located throughout the building. A thorough inspection of the building was not carried out other than those rooms seen when holding discussions with service users. All were clean with no malodour. Furniture and furnishings are of a high quality and many service users have their own possessions displayed. Door keys are provided to ensure privacy and many service users make use of the keys. A number of bedroom doors were locked. Lockable facilities are also provided for personal possessions. Heating can be controlled in individual bedrooms and there is natural ventilation. The laundry was inspected and from discussions with the laundry assistant a good understanding of infection control was shown. The area was clean and tidy and free of malodour. The member of staff had undertaken an NVQ course in general health and safety. This included infection control. Paper towels were available but no liquid soap. Management advised this equipment had been provided but was missing. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30. Staffing levels are not sufficient and at a minimum level must be increased by one full time carer. Recruitment procedures on the whole make sure that staff are suitable before they start work in the home. Training is provided to make sure that staff can carry out their jobs and meet the service user needs. 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 home is well staffed with ancillary staff so that the number of people in the home is high in cases of emergency. One service user said that care staff were very busy and did not have the time to ‘pass the time of day with them’. Care staffing levels were not appropriate for the numbers of service users at the time. It was generally estimated that another full time carer was required. Minimum care staffing levels were discussed with management and regardless of holidays and sick leave these minimum levels must be maintained. If service users needs increase for example due to illness or terminal care then staffing must be increased above minimum levels. NVQ training is ongoing with nine staff attaining NVQ level two in care and another two attending the same course. Three staff are qualified in first aid. Staff confirmed this training. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 17 Records show that induction and foundation training is provided for new staff. All new staff complete an induction programme. This was confirmed in discussions with staff. Supervision of staff is also ongoing. From the three staff files checked recruitment practices were in the majority good. Staff files were well kept with evidence of identity checks, CRB checks and references obtained. One had not provided appropriate references as referees had not been put forward from previous employment in a similar setting. In addition previous details of employment in care homes did not give dates and lengths of employment. The manager was advised to ask for a further reference from a relevant employer and check dates of employment. Job descriptions and terms and conditions were available. Staff confirmed that they were undertaking an infection control course and food hygiene training at the time of this inspection. Staff said that a number of training courses had been attended and more were planned for the coming months. Evidence of training courses attended were in staff files. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38 The manager provides effective leadership. Health and safety of residents and staff is promoted and protected. EVIDENCE: Since the last inspection Ms Tina Davies has been registered as the manager of the home by the CSCI. She is currently undertaking the registered manager’s award. Feedback from service users, staff and her line manager indicates that she manages very well. This was apparent from service users who were encouraged to speak out at the recent meeting. It was said that the manager is approachable and very supportive. Fire checks were up to date and carried out weekly as required. Staff drills are held monthly and include the name of the staff attending . This is good practice. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x x x x 3 Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? 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 27 Regulation 18 Requirement The registered manager must ensure that staffing levels are to minimum requirements. Timescale for action 04.10.2005 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 14 29 Good Practice Recommendations The registered manager continues to discuss the policy of keeping bathroom doors locked. The registered manager to obtain references relevant to experience and ensure dates of employment are recorded. Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley 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. Extracts may not be used or reproduced without the express permission of CSCI Acacia Court 20050906Acacia Court Un Stage 4 J52 V193247 S53221 J52.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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