CARE HOMES FOR OLDER PEOPLE
Acacia Lodge Rookery Road Staines Middlesex TW18 1BT Lead Inspector
Marianne Barham Unannounced Inspection 15th June 2006 10:20 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 Lodge DS0000053851.V300290.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 Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Acacia Lodge Address Rookery Road Staines Middlesex TW18 1BT 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) 01784 452855 01784 441743 Metro Care Homes Limited Miss Carol Ann Evans Care Home 36 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (36) of places Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The Registered Manager must achieve NVQ Level IV in Management by 2005. For one named service user, under 60 years, to receive respite care for a duration of up to 4 weeks twice a year. One named service user under the age of 65 and with a learning disability may be accommodated. One named person under the age of 65 to be accommodated. Date of last inspection 7th October 2005 Brief Description of the Service: Acacia Lodge is a large detached property located in a quiet residential road not far from the main town centre of Staines. The home is owned by Metro Care Ltd and provides accommodation and nursing care for up to 36 older people, one of who may also have a learning disability. The home also offers respite care. The accommodation is arranged over three floors and consists of a dining room, two lounges plus a garden room, a well-equipped kitchen, utility room, three sluice rooms, a main office on the ground floor and the managers office on the first floor. There are three bathrooms and six toilets, all with adapted facilities to accommodate those with mobility problems. The majority of bedrooms are single occupancy, however there are some double rooms available. Most bedrooms have en-suite toilet facilities and those that do not have a hand basin in the room. The property has undergone extensive refurbishment over the last two years and plans further extension and improvements subject to planning permission. There is a good size, well kept garden to the rear of the property that is accessible to the service users and parking for several cars in the car park to the side of the building. Access to public transport is close by. The fees charged range from £525 to £700 per week. Additional charges apply for hairdressing, chiropody, dental and ophthalmic services. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 10.20am by Marianne Barham, regulation inspector on behalf of Kathy Martin, lead inspector for the service. The inspection was undertaken over a period of six hours and ten minutes and all key standards were assessed. The manager, Carol Evans was present and a total of eight service users, six members of staff and four visiting relatives were spoken with, and records relating to care of service users and management of the home were examined during this inspection. What the service does well: What has improved since the last inspection?
The home has reviewed and updated the complaints procedure and provided staff members with training in dealing with complaints so that any concerns are dealt with appropriately and records are maintained. This meets a requirement made at an additional visit carried out on 23rd February 2006. The recruitment files are now maintained in accordance with the Care Regulations 2001 (as amended) and all members of staff now have contracts of employment and job descriptions. This meets a requirement made at the last inspection on 7th October 2005.
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 6 Several areas of the home have been redecorated and/or refurbished as part of an ongoing programme to update and improve the facilities provided, creating a pleasant comfortable environment to live in. 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 Lodge DS0000053851.V300290.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 Lodge DS0000053851.V300290.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. All Service users have their needs assessed prior to moving into the home. EVIDENCE: Pre-admission assessments were examined for four service users, including the most recent admission to the home. The assessment process used by the home is comprehensive and covers physical, social and emotional needs of the individual. Those service users funded by Social Services also have a full needs assessment completed by the Care Manager. It was noted that one service user had not had a review of their needs by the Care Manager for a number of years, this was discussed with the manager and she will contacting the relevant Social Care Team to arrange a review at the earliest opportunity. The manager stated that no service user is admitted to the home unless she is sure that they are able to be met. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Each service user has an individual plan of care, however they are not consistent in the quality of the content. The healthcare needs of service users are met and medication policies and practices protect them. The home generally protects the privacy and dignity of service users, however privacy screens need to be available in the double rooms. EVIDENCE: An unannounced visit was undertaken on 23rd February 2006 in response to a complaint during which a requirement was made that skin assessments were completed for all service users and care plans must be reviewed to provide a clear plan of treatment. Care plans were examined for four service users including the most recent admission. The recording of these is inconsistent, with two being completed to a good standard and the remaining two being poorly completed. There was evidence of monthly review and changes noted. Assessments were in place for
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 10 moving and handling, tissue viability, nutrition, continence, risk of falls and personal hygiene. The manager informed the inspector that two members of qualified staff had recently undergone documentation and record keeping training. This reflects the difference in quality of the care plans seen. The home is in the process of changing the assessment and care planning process to the Standex system, the system has been delivered to the home and will be implemented following training in its use which is to be carried out on 22nd June 2006. The requirement made will be carried forward with a timescale of 31st July 2006 to allow time to transfer to the new system once training has been given. Daily records are maintained and evidence is in place of consultation with specialist practitioners as needed. All service users are registered with a local GP and access district nurses and specialist health professional through the practice. A chiropodist visits service users every six weeks or as needed and optician service visits annually. Specialist equipment and adaptations are fitted throughout the home. Two registered nurses have undergone tissue viability training and a central register of pressure sores, including photographs, and equipment is maintained. The home consults with the tissue viability nurse when necessary. The home has a comprehensive policy and procedure for dealing with medicines. All medications are stored securely and appropriately. Accurate records are maintained for administration of medicines. The controlled drugs register was examined and medication checked against it with no errors found. The temperature on the medication fridge is monitored and recorded. A record is maintained of all medication received into the home. The local pharmacy supplies the medication and also carries out audits and staff training. The home has a contract with the pharmacy for the disposal of unused medication. The home has a policy on privacy and dignity of service users and staff members receive training about this during the induction process. The importance of respecting service users dignity is highlighted in their care plans in the section relating to personal care. Members of staff were observed to interact in a respectful and positive way with service users throughout this inspection. During a tour of the premises it was observed that some double rooms did not have privacy screens, the maintenance worker explained that in some rooms they were being repaired but one room did not have screens at all. A requirement has been made to address this.
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users participate in activities that reflect their individual needs and preferences and they are supported to make choices about their lives. They are able to maintain contact with friends, family and the local community and they receive a balanced diet according to their tastes and needs. EVIDENCE: The home has a programme of events is pinned to the notice board weekly. Activities offered include reflexology, keep fit and bingo. The home also arranges parties for special occasions. Individual records are kept for all activities service users participate in. Service users are supported to attend religious services if they wish and cultural, religious or ethnic needs and preferences are documented in their individual care plans. Friends and relatives can visit the home at any time without an appointment and visitors and service users spoken with said that visitors are made to feel welcome when they visit. Service users likes and dislikes are documented in their care plans and those spoken with said they were able to make choices in their everyday lives, such
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 12 as how they spend their time, who with, when they get up and go to bed and what they eat and drink. Members of staff were observed to offer choices to service users throughout this inspection. The home employs a cook who has worked in the home for several years. All meals are prepared in the well-equipped kitchen and made from fresh ingredients wherever possible. The cook is aware of dietary needs of all service users and was able to discuss individual needs in detail. The meal served during this inspection was chicken pie (homemade) with mashed potatoes and fresh vegetables. All service users spoken with said the food was very good or lovely. Alternative meals were observed being served to those not wanting the chicken pie. It was pleasing to see that the meals that were blended had each part blended separately making the meal more appetising for the service users. The kitchen is clean and all necessary infection control and food safety checks are carried out. Food is stored appropriately and the cupboards are well stocked with a good range of fresh produce. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home handles complaints appropriately and service users are protected from abuse. EVIDENCE: The home has a complaints procedure in place that has been updated and made available to all service users. A copy is also posted on the notice board. This meets a requirement made at an additional visit carried out on 13th February 2006 in response to a complaint made against the service. The home plans to provide members of staff with training on the protection of vulnerable adults from abuse through the company’s internal trainer and some staff members have also undergone training with the Surrey Multi-Agency Team. A copy of the most recent Surrey Multi-Agency Procedures (Feb 05) is held in the nurses’ office. The home has it’s own POVA procedures and a Whistle Blowing policy. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users live in a safe and generally well-maintained environment, however some areas of the home require attention. The home is clean and tidy throughout. EVIDENCE: A tour of the premises was undertaken. The home has undergone extensive refurbishment in the last two years and there is an ongoing programme of redecoration in place. The home was observed to be clean and tidy throughout with no unpleasant odour. The bedrooms are personalised with individual belongings and photographs. Those service users and visitors spoken with said they were happy with their rooms and felt they were comfortable and pleasantly decorated. Some double occupancy rooms did not have privacy screens and a requirement was made that these are put into place.
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 15 The bathrooms were being used for storage of wheelchairs on the first floor and boxes and a sluice machine on the ground floor, restricting access to both. This was pointed out to the manager and the obstructions were removed during the inspection, therefore no requirement has been made. Communal areas of the home include three lounges and a dining room, all of which are pleasantly decorated and comfortably furnished with new carpets throughout. Some areas of the home including the toilets and bathrooms require redecoration and/or refurbishment, as stated previously a programme is in place for this. A requirement has been made that the maintenance/repair or redecoration identified in the programme is carried out. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported and protected by the home’s recruitment procedures, their needs are met by a well-trained, competent staff team that are sufficient in numbers and skill mix to meet their individual needs. EVIDENCE: Staffing rotas were examined and are appropriately maintained, with the rota accurately reflecting the staff on duty during the inspection. The manager is supernumerary and there are sufficient numbers and skill mix of nursing and care staff to meet the needs of service users. Service users and visiting relatives were very complimentary about the staff team, making comments such as the staff are very kind, the staff are wonderful, staff can’t do enough for them etc. At present three members of the care staff have completed an NVQ level two and the remainder are planned to undertake it. The home has a training plan in place for the year that incorporates all mandatory training plus professional development training. Each member of staff has an individual training file containing record of training and certificates. Recruitment files were sampled and found to contain all required checks and information necessary to protect service users. The manager is currently in
Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 17 the process of re-organising the files to make the information easier to access. The home has a policy and procedure in place for recruiting members of staff as well as an equal opportunities policy. All files seen contained job descriptions and contracts stating terms and conditions of employment. This meets a requirement made at the last inspection on 7th October 2005. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is well managed by, a competent, experienced manager and is run in the best interests of the service users, however to comply with legislation monthly audits need to be undertaken by the provider. Service users’ financial interests are safeguarded and the health, welfare and safety of service users is protected. EVIDENCE: The home is managed by, an experienced manager who has been registered with the Commission since June 2003. The manager is currently undertaking the NVQ level 4 registered managers award and, after setbacks owing to a lack of an assessor is now hoping to complete the qualification by December 2006. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 19 The manager is committed to ensuring the continued improvement of the service provided in the home, however she is finding it difficult to manage the large amount of paperwork involved and would benefit from some administrative support. A recommendation has been made that this is provided. The home has introduced a quality assurance protocol with a detailed selfassessment tool that has been developed to relate to the National Minimum Standards for Older People. A survey for relatives and service users has also been developed and it is planned that these will be sent out in the near future. A requirement was made at the last inspection on 7th October 2005 that the registered provider carry out monthly monitoring visits to audit the services and facilities in the home, and a copy of the outcomes must be supplied to the Commission. This has still not been met. The manager informed the inspector that the provider is currently in poor health and has been unable to work for the last two weeks. The inspector was sorry to hear this and wishes the provider a speedy recovery. It is acknowledged that the provider visits the home regularly, however under regulation 26 of the Care Homes regulations 2001 (as amended) these visits must be unannounced and provide a written overview of how the service is operating, therefore this requirement has been made again. The home is not involved in service users’ finances any expenditure above the fees charged is invoiced directly to the service user or a representative. The home has policies and procedures in place for health and safety and all staff members have received training in this subject. Health and safety audits are carried out every three months and these are recorded. General workplace risk assessments are in place and these are currently being updated. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 2 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 1 X 3 X X X Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) (2) Requirement Timescale for action 31/07/06 2 OP10 16 (c) 3 OP19 23 (2) (b) (d) 4 OP33 26 (1) (3) (4) (5) Each service user must have a written plan of care providing clear guidance on how their individual physical, emotional, social and health needs are to be met. The plan must be prepared in consultation with the service user or a representative and kept under review. Screens must be provided in all 30/06/06 double occupancy rooms in order to protect the privacy and dignity of those service users occupying them. The registered person must 31/08/06 ensure that all works required regarding the maintenance, repair, refurbishment or redecoration as identified in the home audit supplied to the inspector is carried out. The registered provider must 31/07/06 visit the home monthly, unannounced and carry out an audit of the facilities and services provided. A written report of these visits must be prepared and a copy supplied to the Commission.
DS0000053851.V300290.R01.S.doc Version 5.2 Acacia Lodge Page 22 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 OP31 Good Practice Recommendations It is strongly recommended that the registered manager is provided with administrative support in order to enable her to carry out her role more effectively. Acacia Lodge DS0000053851.V300290.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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