Inspection on 12/07/05 for Acacia House

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acacia House 21/09/07

Acacia House 04/10/06

Acacia House 27/10/05

Acacia House 26/01/05

Acacia House 10/09/04

Acacia House 24/03/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOME ADULTS 18-65 Acacia House West View Ashington Northumberland NE63 0RZ Lead Inspector Bill Middlemist Unannounced 12 July 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Acacia House Address West View Ashington Northumberland NE63 0RZ 01670 395740 01670 815286 mary.hunter@nmht.nhs.uk Newcastle, North Tyneside & Northumberland Mental Health NHS Trust Mrs Mary Hunter CRH 12 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) Category(ies) of MD Mental Disorder (7) registration, with number MD(E) Mental Disorder - over 65 (5) of places Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26/1/05 Brief Description of the Service: Acacia House provides a service organised on the core and cluster model to people who have enduring mental health problems. The aim of the service is to provide quality psychiatric care and support in a social care setting. The home’s accommodation consists of a six-bedded ‘core’ home and three ‘cluster’ homes, all of which are close to each other. None of the buildings are recognisable as care homes. Each person living in this setting has a single bedroom and a range of other facilities that are in line with an ordinary life in the community. Acacia House is close to the town centre of Ashington, where there are shops, cafes and pubs for people to go to. The home has its own transport and there is a good range of bus services nearby. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection lasted for 4 hours and is one of 2 that this home will receive this year. 5 residents were consulted during the inspection, and 2 members of staff made contributions; the Manager was available for the last part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Each resident has comprehensive assessments carried out by a variety of professionals; the staff at Acacia House carry out their own assessments that lead to detailed care and support plans. EVIDENCE: The files for 3 residents were inspected; each one had assessments that were carried out by a range of professionals depending on individual needs. There was good attention paid to people’s changing needs, and good evidence that assessments promote a way of working that identifies any potential problems early, so that staff can take the right kind of action to get good outcomes for residents. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 ,7, 9 Residents assessed needs are well considered and care plans reflect changing needs. Residents get good support when making decisions about things that are important to them. Risk assessments and risk management plans are well balanced. EVIDENCE: There was good attention paid to people’s changing needs, and several examples of highly individual planning for residents care and support needs. It was noted that some care plans had been discontinued once the preferred outcomes had been achieved, and that plans had been revised as a result of reviews that involved residents. The manager was advised that one resident could benefit from an Occupational Therapy assessment, to promote safety. Residents are assisted to make decisions in a number of formal and informal ways; care planning and outcomes provide evidence of formal decisionmaking, and staff were observed offering residents choices throughout the inspection. Any risks for people living at Acacia house are well documented; risk management plans are particularly good and support people to lead their chosen lifestyle. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 17 People living at Acacia House are able to take part in activities that suit them, and each one is part of the local community. Residents said that they enjoyed the meals they got. Overall, menus are suitable for residents, but on some days meals were not varied as far as healthy choices were concerned. EVIDENCE: Residents told the inspector that they can go out locally that some can do it by themselves and others need staff to be with them. There is a choice of local pubs and restaurants near to the home, and the home has a car if people want to travel further outside the area. During this inspection a number of residents went to a pub in a nearby town with two members of staff, but they had to wait until there were sufficient staff on duty – see Staffing standards below. There was good evidence that a suitable range of activities are provided within the home. All residents said that they enjoyed the meals prepared for them; an inspection of recent menus indicated that there could be a greater variety, for example, on one day sausages were offered at two meals in a row, and the next day, chips were offered at two meals in a row. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 Acacia House is very good at making sure people receive personal support in a way that suits them; the home is also excellent at ensuring that people’s physical and emotional health needs are met. EVIDENCE: Acacia House takes an integrated approach to supporting people and ensuring that their physical and emotional needs are met; each strand of care planning looks at the person as a whole and highlights areas where people may need extra support. The home works closely with a range of other professionals to ensure that any specialist needs are met. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The complaints procedure is easy to follow; all of the residents knew to whom they could complain. The Protection of Vulnerable Adults is prominent throughout the work that Acacia House does. EVIDENCE: No complaints have been logged recently. All of the residents spoken to were aware of the complaints procedure and were clear about whom they could complain to should the need arise. The theme of protecting vulnerable adults runs throughout the care planning and delivery carried out by staff at Acacia House; this is supplemented by staff training in this subject and policies that promote protection. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Acacia House is homely and comfortable and meets the current needs of the people who live there. Parts of the kitchen are slightly damaged and need to be repaired or replaced. This home is kept clean and tidy. EVIDENCE: Residents said that Acacia House was comfortable and each considered it their home. The home is well laid out and supports the kind of lifestyle people want to have. A full inspection of the home was not carried out on this occasion; the kitchen was inspected and parts of work surfaces are damaged and should be replaced. A recent visit from Health and Safety reported the premises as “satisfactory”. All parts of the home that were seen on this inspection were clean, and staff follow recommended hygiene procedures. Cleaning schedules are in line with the home’s “Due diligence” guidelines; this means that everywhere is systematically checked and cleaned. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 All residents praised staff for the way they do their jobs. Staffing levels have not been consistent and need to be addressed to ensure that people receive proper levels of support and social opportunities, in line with the home’s philosophy of social care. The impact of planned and further unplanned sick leave in the near future must be assessed by the Trust, and the appropriate support be put in place to ensure that the service for residents is not diluted or compromised. EVIDENCE: Staff demonstrated that they have good knowledge of each person’s individual needs and how they should be met. Those staff observed on duty during this inspection displayed respect for residents and also demonstrated good values and attitudes. There is a good staff training programme that includes all statutory training, as well as training in subjects that relate directly to the needs of residents; there are also opportunities for staff in continuing professional development. The home has experienced problems with staffing levels because of planned and unplanned sickness levels. Residents informed the inspector that they really enjoyed going out and were eager to go out on the day of this inspection; residents had to wait for extra staff to arrive on duty before they could take part in a social outing. There is further planned sick leave in the near future. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 42 This is a well run home where people clearly benefit from the manager’s way of working. The Trust should ensure that the right systems are in place to support the manager of the home. Good systems are in place to ensure that resident’s opinions about the care and support they receive are heard. All matters inspected relating the Health and Safety of residents and staff were satisfactory. EVIDENCE: The Manager’s skills, knowledge and experience have ensured that Acacia House is well run and that most systems are in place to ensure continued good practice is carried out, and good outcomes for residents are achieved. The Manager currently does not have a Line Manager due to a restructuring within the Trust; this means that supervision arrangements are uncertain and that matters relating to recruitment are unsure. A number of residents questionnaires were inspected and cover a wide range of subjects that are important to residents. These take place periodically and offer an indication of how satisfied people are with the service they receive. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 15 There are unannounced visits made every month by a Responsible Individual from the 3 NNN’s Trust, and a report of findings from these visits, including resident’s views, contribute to Quality Assurance systems. All matters relating to Health and Safety that were inspected were satisfactory, including the Fire Log, Risk Assessments for safe working practices, medication audit, accident book, gas safety records, and complaints. Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Acacia House Score 3 4 x x Standard No 37 38 39 40 41 42 43 Score x 4 3 x x 3 x B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 17 Yes 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. 2. Standard 33 38 Regulation 18.- (1) (a) 18. - (2) Requirement Staffing levels must be reviewed because of planned and unplanned sick leave Arrangements must be put in place to ensure that the Manager is properly supported in carrying out her duties Timescale for action 31st August 2005 31st August 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. Refer to Standard 17 Good Practice Recommendations Menus should be revised in ensure that variety and healthy options are available at each mealtime Acacia House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 House B53-B03 S649 Acacia House V233586 120705 Stage 4.doc Version 1.30 Page 19 - 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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