Inspection on 21/09/07 for Acacia House

This inspection was carried out on 21st September 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Acacia House 04/10/06

Acacia House 27/10/05

Acacia House 12/07/05

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 Anne Brown Key Unannounced Inspection 21 and 24 September 2007 10:30 st th Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 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 House DS0000000649.V346527.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 Adults 18-65. 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 House DS0000000649.V346527.R01.S.doc Version 5.2 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 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) Newcastle, North Tyneside & Northumberland Mental Health NHS Trust Mrs Mary Hunter Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: Acacia House provides a service to people who have 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 one six-bedded home and three small homes, all of which are close to each other. None of the buildings are recognisable as care homes. Each person living in the home has their own bedroom and a range of other facilities that are in line with an ordinary life in the community. Acacia House is very close to the town centre of Ashington, where there are shops, cafes and pubs. The home has its own transport and there is a good range of bus services nearby. The fees are £920.00 per week. Inspection reports and information about the home are readily available. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • • • • • Information we have received since the last inspection on 4th October 2006. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives. The visit • • An unannounced visit was made on 21st September 2007. A further visit was made on 24th September 2007 to speak to the manager. During the visit we: • • • • • • • • Talked with staff and the manager. Talked to the people using the service. Observed the interaction between the staff and the residents. Looked at information about the people who use the service and how well their needs are met. Looked at other records that must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last inspection. We told the manager what we found. What the service does well: The service continues to provide good support and care to the people using the service. Everyone who lives here said that they were satisfied with the care and services they received. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 6 The staff have a very good knowledge of the people who live here and how their conditions affect them, and excellent outcomes are being consistently achieved. This service is well managed and the health and welfare of each person is well considered. The premises are homely, comfortable and well maintained. There are good relationships between the manager, the staff and the service users. Residents are able to take holidays with support from the staff. The residents said they are regularly consulted with regard to the menus and choice is always available. A satisfactory complaints procedure is in place to ensure complaints are dealt with effectively. Comments from the people using the service include: “I like the staff” “The staff are always there to help”. “The staff are very helpful”. “I am very happy living here”. “If the menu doesn’t suit me they will give me something else”. “I enjoy all the food served”. “There is a good choice of food”. “I really like living here and enjoy going to work”. What has improved since the last inspection? Minor repairs have been carried out as required and health and safety issues have been addressed. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 7 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 House DS0000000649.V346527.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Needs are assessed prior to people moving into the home, to help ensure their needs can be met. People are able to visit and spend time in the home to decide whether they want to move in. EVIDENCE: The service continues to carry out a thorough assessment before people are admitted. These are completed by a variety of professionals. The staff at Acacia House carry out their own assessments that lead to detailed care and support plans for the people who live there. These are also discussed when the prospective resident visits the home on a trial basis. Copies of these assessments were available on the case files. People are able to visit the home and spend time there before they make a decision to move in. This helps to ensure that the service can meet their needs. On the day of the inspection a gentleman was present in the home and confirmed that he was visiting the home with a view to moving in permanently. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 10 A meeting also took place between the staff team to discuss how they could meet the needs of this prospective resident and the progress that had been made. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans give a good level of information to the staff to help ensure individual needs are met. Care is planned with the people using the service in a way that they prefer and in a sensitive manner. EVIDENCE: The care plans contain detailed information to help ensure needs are met and look at all areas of the person’s life. Comprehensive guidelines, completed by relevant professionals, are in place to deal with the individual needs of the people who live in the home. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 12 The plans are reviewed and revised on a regular basis. People’s likes and dislikes are recorded. Each person has a weekly planner that describes their preferred routines. Comprehensive guidelines, completed by relevant professionals, are in place to deal with the individual needs of the people who live in the home. The people living in the home confirmed that they are involved in their care plans and the staff consult them about their care. The staff on duty were well aware of the needs of the individual needs of the people using the service and were observed consulting and communicating with them. Risk assessments are available on the case files. These assist the people using the service to lead fulfilling lives and they are well supported by staff to take calculated risks as necessary. The staff have knowledge of equality and diversity issues and these are carefully considered when writing the care plans. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to mix with people in the local community and are well supported to participate in activities of their choice. EVIDENCE: Each resident chooses how he or she spends their time and what activities they wish to participate in. This information is recorded in the daily reports. One person said they were employed in a local café and thoroughly enjoyed this. There are also opportunities to go out in a group or on a one to one basis with staff. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 14 Some people said they enjoyed going to the local pubs and cafes in the area. One person regularly goes to a church in Newcastle. During the inspection a member of staff escorted one person to a local café at their request. The staff had recently supported a group of people to visit a local museum at Woodhorn Colliery. Each person is offered the opportunity to go on holiday every year to a place of their choosing. Two people had enjoyed a holiday in Pitlochry earlier this year. The service has a greenhouse and a vegetable patch. Some people living in the home are interested in growing vegetables and flowers. Staff support people to keep in touch with others, such as relatives and friends, who are important to them. The home ensures that people’s rights and responsibilities are properly recognised in everyday living. Privacy is respected through staff being courteous and only entering bedrooms when they have permission. People are able to spend time in the home as it suits them, they can choose to be with others or spend time alone. Menus are displayed in the main house and staff cook the main meals. The staff encourage people to assist with shopping and cooking. All the people who were spoken said they enjoyed the food and alternatives were always available. The people living in the smaller homes do their own cooking with some assistance from the staff, if necessary. The menus were varied and nutritious and are discussed and reviewed on a regular basis. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and health care needs are well met, and where possible, in a way which the residents prefer. EVIDENCE: The service works closely with a range of professionals to ensure that any specialist needs are met. Records showed that health and well-being is discussed with the people using the service. Any signs that people may not be well are identified and staff have clear instructions on how to act in such situations. Details of health checks, visits to their GP and hospital appointments are recorded in each individuals file. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 16 The manager and the staff on duty were able to describe how people are provided with personal support when they need it. This is fully recorded and the records showed that staff have had training in how to care for people with specific needs. The questionnaires from the people using the service confirmed they were treated well by the staff. Some people confirmed that the staff are always available to assist them if they are feeling unwell. A random sample of medication records and the system for storage and handling medications were looked at and found to be appropriate. The manager and staff on duty confirmed that all staff that handles medications have received adequate training. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are properly dealt with and training in adult protection has been provided for the staff, which helps to protect the service users from abuse. EVIDENCE: A satisfactory complaints procedure is in place and is clearly displayed. All residents have a copy of the procedure. Complaints are recorded along with the outcome of the investigation. This ensures complaints are dealt with effectively and to the satisfaction of the person making the complaint. No complaints have been received since the last inspection. The questionnaires returned by the people using the service confirmed that they knew how to complain and would speak to the manager or staff if they were unhappy. Four people said the staff always listen and act on what they said and three people said they usually did. The service had received three compliments from relatives. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 18 The manager has recently attended a comprehensive course on safeguarding adults. She confirmed that all staff had received awareness training. The staff on duty were aware of the procedure to follow if they suspected abuse. They were also aware of the whistle blowing policy and how to report any concerns about poor practice in the home. A sample of records were examined for money kept on behalf of the people using the service. Appropriate records, receipts and signatures are retained. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes are safe, comfortable and have all the necessary aids and adaptations to support residents’ independence. EVIDENCE: A tour of the main home was carried out. Two smaller houses were also visited. All areas of the home were homely, comfortable and well furnished. However many areas are showing signs of wear and tear. The décor in the communal areas in the main house is shabby. The carpets in bedroom two and the downstairs corridor are stained. The décor in the living room of one of the smaller homes was stained with nicotine. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 20 The manager stated that a refurbishment programme was due to commence in the near future. The people who live in the home have their own bedrooms that are decorated and personalised according to their wishes and tastes. Bedrooms are equipped to ensure the comfort and safety of the individuals and specialist equipment is provided to promote independence. The fax machine and computer system used by the staff are currently located in the lounge. This impinges on the residents’ space and could cause problems regarding confidentiality. Gardens are well maintained and provided with garden furniture. All areas were clean, hygienic and free from offensive smells. The manager receives information from the infection control nurse on a regular basis. A member of staff has also undergone infection control training and has cascaded this to the staff team. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff, who have been properly recruited, trained and supported, to meet the needs of the people living in the home. EVIDENCE: Staff continue to demonstrate that they have good knowledge of each person’s individual needs and how they should be met. Those staff observed on duty displayed respect for service users and 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 to continue professional development. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 22 During the day there is a minimum of two care workers, domestic assistant and housekeeper on duty. Overnight there is one waking care worker and one sleep in care worker on duty. The staff felt staffing levels were adequate to meet the needs of the people using the service. The service employs nine female care workers and four male care workers. Four qualified nurses are employed in the service. Four care workers have achieved National Vocational Qualification (NVQ), Level 2 or above and four members of staff are working towards achieving this. An appropriate recruitment and selection process is in place. been employed since the last inspection. No staff have A programme is in place to ensure all staff receive formal supervision. intervals. The staff on duty confirmed they are supervised on a regular basis. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The culture and systems in the home help to ensure that the service is led by the needs and wishes of the residents, and protects them from harm. EVIDENCE: The manager’s skills, knowledge and experience have ensured that Acacia House is well run and that systems are in place to ensure continued good practice is carried out, and good outcomes for residents are achieved. The staff members who were spoken to said the manager was approachable and supportive. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 24 The people using the service said the manager was helpful and one said ‘she is always happy to solve any problems’. The staff on duty confirmed that regular meetings are held to discuss any issues that arise and to ensure the home is run in the best interests of the residents. Minutes of the meetings were available for inspection. There are comprehensive policies and procedures in place to safeguard the rights and best interests of the service users. The manager stated that monitoring visits are made by a senior manager on a monthly basis. This is to check that the people who live there get the care they need and their health, safety and welfare is promoted. However the last report available in the home was dated 16th December 2006. The manager confirmed that tests are carried out on the fire fighting and detection equipment at the correct intervals. However the latest test had not been recorded in the fire log book. The housekeepers maintain charts to record water and fridge/freezer temperatures. However these had not been carried out in their absence. The manager addressed these issues during the inspection. The staff on duty confirmed that they receive up to date health and safety training to help protect the safety of themselves and the residents. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 26 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 YA39 Regulation 26 Requirement The registered person must make sure that all copies of the reports from the monitoring visits are held at the home so any issues can be addressed. Timescale for action 30/11/07 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. Refer to Standard YA24 Good Practice Recommendations Refurbishment programme should commence as soon as possible to ensure all areas of the service are pleasant and well maintained. Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acacia House DS0000000649.V346527.R01.S.doc Version 5.2 Page 28 - 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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