Inspection on 16/04/07 for Acacia House Nursing Home

This inspection was carried out on 16th April 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 House Nursing Home 02/11/05

Acacia House Nursing Home 12/04/05

Acacia House Nursing Home 12/10/04

Acacia House Nursing Home 28/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Acacia House Nursing Home 33 Portsmouth Road Horndean Hants PO8 9LN Lead Inspector Mrs Pat Hibberd Unannounced Inspection 16th April 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 House Nursing Home DS0000055653.V333500.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 House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acacia House Nursing Home Address 33 Portsmouth Road Horndean Hants PO8 9LN 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) 023 92 594138 Contemplation Homes Ltd Mrs Linda Murray Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 55 years of age. Date of last inspection 2nd November 2005 Brief Description of the Service: Acacia House is in a residential area on the outskirts of Horndean, near Portsmouth. It is a care home providing nursing care for people aged 65 years or over. The home is also registered to admit terminally ill service users and up to five service users between the ages of 55 and 64 years. The home is arranged over two floors, with three ground floor communal rooms, including a large sunroom with views into the garden. There are twenty-three single bedrooms and two shared bedrooms. There is a shaft lift for access to the first floor. There are stairs to four bedrooms on a half-landing and to one of the shared bedrooms on the ground floor. There is a portable stair lift to provide access to these bedrooms. The home has attractive, well maintained, gardens to the rear of the property, which are accessible to residents. There is a small car park at the front of the home. Current fees range between £590.00 - £795.00 per week. This information was provided by the manager on 29/03/07. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over one day. The people living at Acacia House prefer to be referred to as residents; therefore the rest of this report will reflect this. The opportunity was taken to look around the home, view records, procedures and talk with residents and staff. The inspector also had the opportunity to observe the interaction between residents and staff. Four residents were spoken with who stated that they were more than happy at the home. Conversations were also held with a number of visiting relatives and a GP. Questionnaires completed by residents were seen and views expressed will also be detailed in this report. A pre inspection questionnaire was received by the commission prior to the visit to the Home of which information provided will be included throughout this report. What the service does well: What has improved since the last inspection? Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 6 There were no areas of improvement identified at the last inspection. However, the Home continues to develop activities for residents and, has a rolling programme of decoration of which both residents and relatives spoken to felt this indicated that they were valued by the Providers. 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 Nursing Home DS0000055653.V333500.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 House Nursing Home DS0000055653.V333500.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. This judgement has been made using available evidence including a visit to this service. A full care assessment is undertaken for everyone wishing to live in the home to ensure the home can meet their care needs. The home has the facilities to provide respite care to residents who have been assessed as requiring short-term care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager explained the assessment process she follows, in line with company policy, and showed the inspector the information that is available to prospective residents, which includes details that would enable people to make an informed choice about the home. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 9 Feedback from one resident and two relatives stated that they had received information from the home, which enabled them to decide that they wanted to visit the home to view the facilities and environment. Prospective residents and their families/ representatives are welcome to look around the home to see if the home would meet the individual’s needs. The inspector looked at the two most recent pre admission assessment records. The manager had visited the prospective resident to complete the home’s pre admission assessment before a place was offered at the home. This was to ensure the home could meet their individual needs. The resident’s family were involved and asked to provide further information. The pre admission information includes a moving and handling assessment, medical history, allergies, history and risk of falls, equipment needed, personal care needs, personal preferences, medication and any anxieties etc. A discussion was held with the manager as to how a prospective resident whose first language was not English could receive the information they required to make an informed choice as to whether Acacia House could meet their needs. The manager explained that they would use the services of an interpreter and advocacy if required. The home provides two rooms for the “Rapid Response “ team that provides intermediate care for the individual for up to six weeks. The inspector spoke to a relative of one resident who had recently been admitted for this purpose. Feedback included “ they assessed my husband before he was admitted and have looked after him so well”. The rooms used for the purpose of intermediate care are tastefully decorated and had colour coordinated furnishings and a telephone point in case the resident wished to be connected to the telephone service. The manager showed the inspector letters that she sends out once a prospective resident has decided that they would like to live at the home. Once the manager is satisfied that the home can meet their needs, the home send a letter offering the prospective resident a place. The letter confirms which bedroom the resident will have. The resident’s contract states the fees that the home will charge them. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 10 Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 11 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. This judgement has been made using available evidence including a visit to this service. Residents who are able are involved in the development and review of their care plans and their health care needs are met. The home’s processes of storing and handling medication need to improve to appropriately protect residents. Residents feel that they are treated with respect at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector looked at four residents’ care plans. The plans were very comprehensive and contained the information gathered during the pre admission assessment. Staff said the care plans provide them with the information they need in order to provide the exact care and support the resident needs. The manager and Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 12 staff said they review the care plans with the resident on a monthly basis, records seen confirmed this. The inspector was unable to confirm with all resident’s spoken to as to whether they were aware of what was written in their care plans due to the complexity of their needs. However, staff were observed throughout the day sensitively explaining to individuals as to what support they were providing and checking at each stage that the resident was comfortable and happy. Where able care plans had been signed and dated by the resident or their representative and by staff. One care plan gave clear guidelines for staff to provide care to a resident who is bed fast and requires regular turning and personal care. From discussions held with one staff member and observation of care provided by a number of staff the inspector commends the respect and dignity shown to the residents. Three relatives and four residents spoken to supported this view. Risk assessments were included in the care plans including those for mobility, falls and nutritional risks. The manager confirmed that if staff have any concerns regarding nutrition of residents, dietetic advice would be sought. All risk assessments are specific to individual residents, for example for those residents who are bed fast and for those with mental health needs. For two residents who had a pressure area care plans were in place and staff spoken to were aware of the content of the care plans. However, whist there is a general risk assessment policy and procedure for assessing the needs of those residents requiring bed rails for their safety one file viewed did not hold an individual risk assessment. The manager indicated that all residents should have a risk assessment for the use of bed rails that should be kept under review. The risk assessment was completed during the inspection visit. All other residents requiring bed rails had a risk assessment on file that had been regularly reviewed. Records showed that residents receive visits from GPs and other health professionals such as the physiotherapist, psychiatrists and occupational therapist if required. A visiting GP confirmed that he received good information from the Home and considered the care to be of a good standard. A trained nurse administers medication and there is a medication policy and procedure in place, including the ‘Royal Pharmaceutical Society of Great Britain’ guidance for the administration and control of medicine in care homes. The home administers the majority of medication from single blister pack system provided by the local pharmacist. Medication is correctly stored in two lockable medicine trolleys, which were seen to be stored in the medical room. There was a controlled drugs cupboard also in the medical room. However, when inspecting the medication administration records for one resident for medication not held in a blister pack there was some discrepancy Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 13 on one sheet as to the number of tablets administered and the number of tablets contained in the box. There was also medication held in the controlled drugs cupboard that had not been required by two residents since February 2007 but had not been returned to the pharmacy with other medication that is collected from the Home on a regular basis. As the medication was all the same medication albeit a different dosage the manager agreed that this could cause confusion and potentially result in a resident being given the wrong dose. The manager commenced an audit of all medication during the inspection and confirmed that an audit would take place weekly until she was satisfied that there were no further errors. An alternative, larger but appropriate cupboard was identified to store controlled drugs during the inspection visit and all medication no longer administered removed. The manager confirmed that at the time of the inspection no residents were self administering their medication. Each resident’s medication record has a recent photograph. The inspector observed the staff interacting with the residents and found them attentive, caring, respectful and they have a good understanding of each individual’s needs. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that the carers treat them with dignity and respect and that they are trustworthy. Four resident told the inspector that staff respected their choice and privacy at all times. Throughout the visit, staff were seen to knock on doors and wait before entering rooms and they spoke to residents in their preferred manner, as stated in their care plans, and were friendly but respectful. Staff said they are aware of the importance of dignity and respect, one staff member said, “ I treat people as I wish to be treated”. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: Residents spoken to felt they are able to exercise choice by participating in social activities if they wish, one resident said ‘I can join in with any of the activities if I wish, and I am free to spend time as I wish.’ The home employs one of the care staff for six to eight hours a week as an activities co-ordinator. The activities, for those who wish to take part, are advertised within the home by posters made by the homes administrator. The activities include theatre visits, a firework party, Christmas shopping and a visit to the home by a mobile farm. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 15 A range of activities also took place over the Easter period including an Easter Egg Hunt. There have been outings to Portsmouth and Southsea. The manager said there were plans to take some of the residents to the military museum in Portsmouth. The Home has a budgie that is housed in the sun lounge and cared for by all residents who so wish to. Resident’s preferences are identified during the assessment process, and this information is included in the individual’s care plan, therefore staff are aware of what residents like doing. During a tour of the home the inspector saw several bedrooms that had been personalised with the residents own possessions, such as small pieces of furniture, pictures and ornaments. Residents can attend church if they so wish. Ministers visit the home to provide communion for those who wish to take part. Visitors are encouraged; there is open visiting and residents may entertain their visitors in the communal rooms or their bedrooms. Visitors that spoke with the inspector commented that they were always made welcome and were happy with the care provided by the home. The chef has worked at the home for several years and in discussions held was familiar with the likes and dislikes of the residents. The menus are varied and offer choices to cover all tastes. The chef visits the residents to chat and check their dietary preferences. The kitchen was clean and all food stored appropriately. Snacks are available and residents can choose where to have their meals. Residents spoken to said that they liked the food that is provided and were always able to choose what they had for their meals. Due to the hot weather notices were seen around the Home reminding staff to ensure all residents have sufficient drinks. Throughout the day the inspector observed residents with juice in addition to hot drinks being offered. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 16 Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 17 Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 18 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): Standards 16 and 18. Quality in this outcome area is good. The policies and procedures that are in place for protecting residents and responding to any concerns are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two complaints have been received by the home in the last twelve months. These were seen to have been dealt with appropriately. The home has a clear complaints procedure, which is available to residents and their relatives although due to the needs of most residents they would have little concept of how to complain. However, relatives spoken with during the inspection said they knew about the complaints procedure, who they could complain to and where to obtain the relevant information. Staff spoken to said that much time is spent observing residents and amending care plans if they noted that they seemed unhappy with any aspect of service provision. Two residents said that they welcomed CSCI inspections as well as the monthly-unannounced visit by the service manager [Regulation 26 visits] as their role is to monitor and ensure the well being of the residents. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 19 The home has a copy of the Hampshire abuse procedure and from discussions held with staff it was evident that they had a good understanding of the various types of abuse and had benefited from training provided. The manager confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. The manager confirmed in the pre inspection questionnaire that there have been no incidents of abuse recorded in the home. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 20 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): Standards 19 and 26. Quality in this outcome area is good. The home provides a clean, comfortable and safe standard of accommodation for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was warm and very welcoming, at the time of the visit the home looked extremely clean. The home has a maintenance programme to ensure the Home is kept in good order with a rolling redecoration programme in place. A new facilities manager has recently been employed and is responsible for all health and safety matters and maintenance. One resident said the home is always clean. The manager explained the home currently employs one domestic staff member but due to the size of the Home Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 21 a further domestic had been employed and would start work at the Home within the next week. In discussion with the current domestic staff member it was evident that she takes great pride in her work to ensure the home is always clean. Acacia House has a ‘homely’ feel by ensuring the communal areas look inviting, for example the dining room tables were laid very nicely for lunch, and the quiet area had a table lamp providing soft lighting, ornaments and flowers and comfortable chairs for both residents and visitors. The dining room has recently been “swapped” with one of the small lounges. In discussion with residents and relatives they considered this to be a positive move as the new lounge area is in a more appropriate part of the Home enabling increased interaction with staff and other residents for those who so wish. Accommodation is provided over two floors. Access to the first floor is by a passenger lift, and a number of flights of stairs. The Home also has a special chair lift that can be used on the stairs to transport residents. There was ample communal space for residents and their visitors to use, the majority of which overlooks the well-maintained gardens and a small patio courtyard garden. Resident’s bedrooms looked very comfortable and contained many personal items such as pictures, furniture and ornaments. Two residents spoke of their satisfaction with their rooms with comments of ‘it’s very comfortable, the staff ensure it is cleaned every day, my bedding and towels are regularly changed ’ and ‘What more could I ask for, I have everything I need’. ‘My room is decorated to my taste, and I have a good view of the garden.’ Residents bedrooms cannot at present be locked therefore residents do not hold a key to their room. However, the manager indicated that locks are to be fitted to all bedrooms and for those residents who wish to and are able to hold a key will be provided with one. No views were gained from residents, although this will be followed up at the next inspection. All residents spoken to said they feel safe and secure in the home and the grounds. The majority of communal areas in the home let in plenty of natural light. Residents were observed to walk freely around the home independently or with the assistance of staff or various walking aids. The home has an internal laundry that is well equipped. Infection control procedures were in place. Staff were observed to follow these guidance, equipment such as gloves and aprons were available, so too was antibacterial hand gel for staff and visitors to use. Staff indicated that they had received infection control training. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 22 The garden is well maintained and is accessible to the residents. The gates are locked to ensure the safety of residents due to there being an extremely busy main road at the end of the drive. A handyman employed by the home does the routine maintenance. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 23 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. This judgement has been made using available evidence including a visit to this service. Residents feel that a sufficient number of staff are on duty to meet their individual and group needs. There is sufficient skill mix within the team and to meet the residents needs. The homes comprehensive recruitment practices ensure resident’s safety. Staff receive mandatory and specialist training and are supported to obtain NVQ level 2 or above. EVIDENCE: Residents spoken with said there are always enough staff on duty that know how they like to be cared for. Discussions held with staff indicated that in general they felt there are enough staff on duty on each shift. Rotas indicated that there are always 5 – 6 staff on duty in the morning, 3-4 in the afternoon and 3 at night. . The manager confirmed there is always at least one trained nurse, (this does not include the manager) on each shift. It was evident from practices and interactions observed that staff had developed a good relationship between themselves and residents. Comments Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 24 from residents included that staff were very kind and always helpful and that they were a “good team”. Staff said they receive regular formal supervision by their line manager; this gives them the opportunity to discuss any training needs they may have. Staff further indicated to the inspector that they receive very comprehensive handovers of information at the beginning of each shift, and that the trained nurse who is the ‘shift leader’ allocates work to staff according to their skill mix, which makes for an effective staff team. The manager confirmed in the pre inspection questionnaire that 70 of the fifteen care staff employed at the home have received an NVQ (National Vocational Qualification) level 2, the home employ seventeen first level nurses and two second level. The staff confirmed that they undertake training regularly in the necessary health and safety subjects such as fire safety, first aid, moving and handling, health and safety, infection control and food hygiene. Other training courses planned include more NVQ’s, Phlebotomy courses, Wound care courses, Syringe driver course, dementia training and Liverpool Care Pathway. The staff stated that the recruitment process within the home is thorough. The inspector was able to see four different staff records and found that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. Other records seen on file include signed contract of employments, job descriptions and criminal record bureau and protection of vulnerable adults register. Staff spoken to said that they feel the induction programme run by the home was useful and detailed. The files seen held records of the individual staff induction training covering the key areas with the signatures of the staff member and trainer. The manager confirmed that the home’s induction programme meets the recently amended Skill For Care standards for induction. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 25 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. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent to run the home. Management and administration of the home is based on openness and respect. An effective quality assurance system is in place. The home is not involved in monitoring or handling residents’ money. Residents’ health, safety and welfare are promoted by the home with systems that ensure everyone is protected within the home. EVIDENCE: The manager Linda Murray has recently been registered with the Commission. She has the required experience, is competent to run the home and is a registered nurse. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 26 The manager says she is committed to quality assurance and continuing development of the service. There is a strong ethos of being open and transparent in all areas of running of the home, and residents who were able to comment indicated that they felt they were involved in the development of the home, and were confident in the manager’s ability. Staff further supported this view and observations showed there are clear lines of accountability within the home. Also the management approach of the home creates an open, positive and inclusive atmosphere. The staff felt they were included in the day-to-day decision making within the home with the manager indicating that staff meetings are due to commence in the next month. Residents said that they felt able to give their views, which they feel are valued, on the quality of care provided at the home to the manager and feel involved in issues affecting the home. Residents spoken with commented that management and staff are very approachable, always make themselves available and readily help with any problems. They also had nothing but positive comments to say about staff that included – “They really care”, “They don’t rush you” and “Staff are very kind”. A quality assurance and monitoring system based on seeking the views of residents, relatives and professionals is in place. As well as completing questionnaires, residents told the inspector that management are always asking how things are and if they would like anything different. Residents spoken to said if they are not happy with something, all they need to do is tell someone, and it will be seen to. The manager said resident’s family or financial appointees safeguard resident’s money, rather than the home, one relative confirmed this. With the exception of the requirements raised earlier in this report relating to medication and bed rails no other unsafe practices were observed during the inspection. Certificates were available for required checks of systems and equipment. Risk assessments where necessary have been completed. Staff have received training in health and safety, first aid, fire safety, care of substances hazardous to health and moving and handling. The fire drill records showed that all staff had attended at least two fire drills in the last year. Regular risk assessments are undertaken and recorded to ensure that the safety within the home room by room. These were sampled and found to be satisfactory. The manager explained the recording system for fires safety maintenance, training, evacuation and visual checks. The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals to ensure the safety of the residents. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 27 The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being utilised within the home The home has a policy, procedures and information on health and safety. A sample of policies and procedures were forward to the commission prior to the inspection visit and had recently been reviewed. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including bath aides received regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 28 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Acacia House Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Nursing Home DS0000055653.V333500.R01.S.doc Version 5.2 Page 31 - 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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