Inspection on 28/08/07 for Acacia Lodge

This inspection was carried out on 28th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Lodge 20/09/05

Acacia Lodge 09/05/05

Acacia Lodge 27/10/04

Acacia Lodge 13/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Acacia Lodge Acacia Lodge 37-39 Torrington Park Finchley London N12 9TB Lead Inspector Daniel Lim Key Unannounced Inspection 28th August 2007 09:30 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 DS0000010392.V343503.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 DS0000010392.V343503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Address Acacia Lodge 37-39 Torrington Park Finchley London N12 9TB 020 8445 1244 020 8343 7459 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) Mr Michael David Pringsheim Mrs Janet Wairimu Bethuel Mrs Marie Conely Care Home 32 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (4) of places Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2006 Brief Description of the Service: Acacia Lodge is a care home registered to provide care for a maximum of thirty two older people. It is owned by Mr Michael David Pringsheim and Mrs Janet Wairimu Bethuel. The home was first registered in 1971. The home’s stated aim is to stimulate and help maximise each resident’s physical, emotional and social capacity, so that they remain mentally and physically active, subject to any personal limitations, which will always be respected. The home is a detached three storey house with fourteen single bedrooms and nine shared bedrooms located across the three floors of the building. On the ground floor, there is a kitchen, laundry room, toilets, bathrooms, large lounge, dining room and bedrooms. On the first floor there is an office, small lounge, toilets, bathrooms and bedrooms.On the second floor there are toilets, bathrooms and bedrooms. A shaft lift is available from the ground to the first floor and a stair lift is provided from the first floor to the second floor. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is located in a quiet residential area of North Finchley close to shops, restaurants and transport links located along the High Road. The home has a registered manager (Marie Conely). She is supported in her management role by an administrator (Nicki Deakin). The fees of the home range from £404.00 to £550 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 28th August 2007 and took a total of six hours to complete. The inspector found that the care provided was of a high standard and the previous requirement made had been complied with. During this inspection, the inspector was assisted by the manager of the home (Ms Marie Conely) and the home’s administrator (Mrs Nicki Deakin). The inspector was able to interview four residents. The feedback received from them indicated that they were satisfied with the care provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record, financial records and fire records of the home. These records were generally well maintained. The premises including bedrooms, bathrooms, lounges, treatment room, kitchen, garden and communal areas were inspected. These areas were clean and tidy. Five staff on duty were interviewed on a range of topics associated with their work. Staff records, including supervision records, evidence of CRB disclosures, references and training records were examined. Staff on duty were noted to be knowledgeable. The minutes of staff and residents’ meeting were also examined. A record of compliments received from residents and their relatives had been kept. In addition, a relative, a resident’s friend, a social worker and a healthcare professional (community nurse) were interviewed. The feedback received from them indicated that residents were well cared for. What the service does well: Feedback from residents indicated that they had been treated with respect and dignity by staff. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 6 The premises were clean and felt homely. Bedrooms were well furnished and appeared cosy. The gardens were attractive and well maintained. The arrangements for the provision of meals was of a high standard and the ethnic meal preferences of residents had been responded to. The home had a comprehensive training programme for staff. Staff were knowledgeable regarding their roles and responsibilities. They indicated that they worked as a team. The manager and her staff co-operated fully with the inspector and the required pre-inspection information had been provided. What has improved since the last inspection? What they could do better: The registered person must provide evidence that residents (or their representatives) have been consulted regarding their care plans. This evidence could be in the form of signed care plans. This is to ensure that residents (or their representatives) are fully consulted and agree with their care plans The registered person must ensure that the fire alarm is tested weekly and documented. This is to ensure that any defect affecting fire safety is promptly identified and rectified. The registered person must provide residents (or their representatives) with the opportunity to sign for items or valuables deposited in the home’s safe. This is required to provide evidence and details of ownership of items deposited. The registered person should review the provision of activities and ensure that residents are provided with appropriate daily social and therapeutic activities. This is to ensure that residents are stimulated and have access to appropriate activities. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 8 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 DS0000010392.V343503.R01.S.doc Version 5.2 Page 9 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 People who use this service experience a good outcome in this area.This judgement has been made from evidence gathered both during and before the visit to this service. Evidence suggests that admissions are not made to the home until a full needs assessment has been undertaken by the manager. The assessments were satisfactory. Admissions only take place if the service is confident that the needs of people to be admitted can be met and staff are able to provide the required care. This ensures that the admissions to the home are appropriate. EVIDENCE: Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 10 The case records of two residents who were admitted since the last inspection of the home were examined. They contained comprehensive pre-admission assessments carried out by the manager. These assessments met the required standard and there was documented evidence in the case records that the needs of these residents had been attended to. Comprehensive risk assessments together with strategies for minimising risks had been prepared by care staff. These included risk assessments for falls. An appropriate care plan had been prepared for each resident. The care provided had been reviewed with professionals involved. The manager informed the inspector that the home does not provide intermediate care. Acacia Lodge DS0000010392.V343503.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 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. Satisfactory arrangements for personal, specialist healthcare and dietary requirements were in place. Personal support provided was responsive to the individual needs and preferences of people who use the service. The service was sensitive to the changing needs of residents. This ensures that the healthcare and personal needs of residents are met. Residents interviewed were happy with the care provided. EVIDENCE: Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 12 The three residents interviewed, indicated that their healthcare and personal needs had been met. Comments made by residents included, “I can see the doctor when I need to”, “my medication had been given to me by staff”, and “the staff take good care of me ”. One relative and a friend of a resident who were interviewed were able to confirm that the health and personal care of residents had been attended to. The sample of four case records examined were up to date and plans of care examined, were appropriate. These had been reviewed monthly and some (2) had been signed by either residents or their representatives. The signing of care plans was discussed with the manager. To ensure that residents (or their representatives) are fully consulted and agree with their care plans, evidence in the form of signed care plans is required. There was documented evidence that people who use services have access to healthcare when required. A record of medical and healthcare visits / appointments had been kept. This included chiropody, dental and optician’s appointments. The visiting community nurse was interviewed. The feedback received from her indicated that she was satisfied with the arrangements for meeting the nursing & healthcare needs of residents. She stated that the home maintained close liaison with her and her instructions regarding nursing matters had been followed. The weather was warm on the day of inspection. Guidance had been provided for staff regarding how to prevent dehydration. Staff were noted to be offering drinks to residents. The home had several residents with diabetes. The case records of one of these residents with diabetes were examined. A diabetes care plan had been prepared. The medication charts examined indicated that the required medication had been administered. When interviewed, staff were aware of the care needs and dietary requirements of residents with diabetes. The community nurse interviewed stated that she was satisfied with the care arrangements for residents with diabetes. The arrangements for the administration of medication (including the policy and procedures) were noted to be satisfactory. A record of daily fridge and room temperatures had been kept. These were satisfactory. Medication administration charts (MAR) were appropriately filled in. Staff responsible for administering medication had been provided with the required training. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 13 The inspector noted that staff regularly interacted with residents when attending to them and they were respectful in their approach. Residents were clean and appropriately dressed. One relative and a friend of a resident who visited the home regularly, indicated that staff were friendly and residents had been treated with respect and dignity. The manager provided an example of good practice where a resident had improved physically and mentally and was able to join in activities within the home. This resident had been admitted with mobility problems and was initially very apprehensive and unwilling to participate in activities. As a result of appropriate care being provided, improvements had been noted. There was documented evidence in the case records of the improvement made. Acacia Lodge DS0000010392.V343503.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 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The daily life, meal arrangements and routines of residents were on the whole, well organised. The service has a commitment to enabling residents to remain as independent as possible and there is opportunity to engage in meaningful activities. Personal and family relationships are being maintained. This ensures that the personal, cultural and social preferences of residents are met. EVIDENCE: The home had a varied programme of weekly social and therapeutic activities. The programme which was available for inspection included exercise sessions, outings, manicure, knitting, music sessions, birthday celebrations, cheese & wine party, bingo and art and crafts sessions. Residents interviewed were generally satisfied with the activities provided. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 15 A record of activities that residents had engaged in had been kept. The inspector however, noted that on some days, such as weekends, no activities were documented. This was discussed with the manager who explained that sometimes activities were not possible as staff were busy. At other times, activities take place at the discretion of staff. To ensure that residents have regular access to a range of social and therapeutic activities, a recommendation is made for the home to have a programme of daily and appropriate activities. A resident indicated that she would like to attend church services. This was discussed with the manager who provided documented evidence that this suggestion had been responded to. The kitchen was clean and well equipped. A record of fridge and freezer temperatures had been kept. These were satisfactory. Residents interviewed indicated that they were satisfied with the meals provided. The chef had worked in the home for many years and was knowledgeable regarding the preferences of residents. He was also aware of special meals to be provided. These included meals for residents with diabetes and swallowing difficulties. The menu which was examined, appeared varied and balanced. There was documented evidence that the ethnic dietary preferences of residents had been catered for. Meals provided included ethnic foods such as curries, spaghetti Bolognese, risotto and Chinese stir fry dishes. Food hygiene training had been provided for staff and documented evidence was available in staff files. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 16 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): 16, 18 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents are well treated and protected from abuse. This was confirmed by residents who said they were happy with the service provision and they had been well treated. EVIDENCE: The arrangements for adult protection were discussed with the manager. There was documented evidence that staff had been provided with adult protection training and when interviewed, the manager and her staff were aware of the procedure to follow when responding to allegations of abuse. The issue of equalities and diversity was discussed with the manager and her staff. The manager provided evidence that the home had an equalities and diversity policy and procedure. Her staff indicated during their conversation with the inspector that they had been instructed to treat all residents Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 17 sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. The complaints record was examined and it was noted that complaints recorded had been promptly responded to. This included a complaint made by a relative. This relative expressed concern (to the manager, social services and inspector) regarding the transfer of a resident to a nursing home. The manager explained that the home was unable to meet the resident’s assessed needs and a transfer was necessary as this resident had high needs. The inspector noted that that discussions had taken place between the relative, the manager and social services and this matter was now resolved. A record of compliments received by the home had been kept. These indicated that relatives were satisfied with the care provided and they thought highly of staff. Comments made by relatives included the following: “ God bless you all. Thank you for all the kindness you show dad. With all our thanks for all of your wonderful care Thank you so very much all of you for looking after our mother. It is so wonderful to know she is being looked after so well. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 22, 23, 24, 25, 26 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. It is clean, tidy, well equipped and appropriate aids and equipment had been provided. The bedrooms are comfortable, cheerfully decorated and people who use the service can personalise their bedrooms. During interviews, people who use the service say they are happy with the accommodation provided. EVIDENCE: Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 19 Plants and flowers were displayed in the home. Daily checks of the premises had been carried out to ensure that the premises are safe and deficiencies are noted and rectified. The home had an ongoing programme of routine maintenance. The maintenance person who was present stated that repairs are promptly carried out. The bedrooms and communal areas inspected were clean and well furnished. No safety hazards were noted. No offensive odours were detected. The dining room was comfortable and overlooked the garden. Bedrooms inspected appeared cosy and well furnished. Lockable facilities had been provided so that residents who wish to lock away their personal items can do so. Bedrooms had been personalised by residents with their own pictures and ornaments. Residents who were interviewed stated that they were happy with the accommodation provided and their bedrooms had been kept clean. The laundry room was inspected and noted to be well equipped. Staff were aware of the need to wash soiled linen at a temperature of at least 65 C for at least 10 min. Specialist equipment available in the home included 5 wheelchairs, 1 assisted bath with hoist and 2 hoists. Ramps were located near the front doors and the reception for easy access by those needing a wheelchair. These equipment are provided to ensure that residents can be safely cared for and can move freely in and around the home. The gardens were accessible (ramp provided), attractive, colourful and seating had been provided. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 20 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 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing arrangements were satisfactory. People who use the service and their representatives have confidence in the staff who care for them. Rotas indicate that the staffing levels were good and staff had the required training. This ensures that residents are well cared for. EVIDENCE: The training records examined, indicated that staff had been provided with the required training (such as health & safety, moving & handling, care of residents with dementia illness, fire training, food hygiene and adult protection). Four staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. They informed the inspector that they were happy with the way they were managed and there was a good team spirit among staff. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 21 Staff stated that they had been instructed to treat all residents with respect and dignity regardless of their race, sex, religion or sexual orientation.This was confirmed in the induction programmes seen. Residents who were interviewed indicated that staff were respectful and they were responsive towards them. This was confirmed by a relative and a friend of a resident present. Staff were noted to be interacting with residents and respectful in their approach towards them. No concerns regarding staffing levels were expressed by those interviewed. Staff stated that they were able to complete their care duties. The duty rota was examined. Staffing levels consists of 5 carers in the morning, 4 carers in the afternoon & evenings and 3 carers on waking night shift. The manager and the administrator were supernumerary. Ancillary staff working at the home consists of 2 chefs, four kitchen staff, two cleaners, a maintenance person and an administrator. The level of staffing was adequate for the home and ensured that residents were well cared for. Recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures and two references) had been followed. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 22 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 People who use this service experience a good outcome in this area. This judgement has been made from evidence gathered both during and before the visit to this service. The home was run in the best interest of residents and satisfactory arrangements were in place to ensure the safety and welfare of residents in the home. The manager has a clear understanding of the key principles and focus of the service. She works continuously to improve services and provide an increased quality of life for residents. EVIDENCE: Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 23 The manager and administrator informed the inspector that they endeavoured to be responsive and approachable to residents and staff and adopted an “open door” policy. This was confirmed by those interviewed who stated that they were approachable and the home was well managed. The registered manager had received her RMA (Registered Manager’s Award). She had attended periodic training. She was knowledgeable regarding her responsibilities and the needs of residents. Records and documents required for this inspection were promptly provided by the administrator and manager. Both the manager and administrator had a detailed understanding of the needs of residents and stated that they were keen that residents are provided with a high quality of care. Issues affecting the management of the home that needed clarification during this inspection (and prior to the inspection) had been promptly responded to. Residents, staff, one relative, a friend of a resident and the community nurse expressed satisfaction and confidence at the way the home was managed and the care provided. There was evidence that staff and residents meetings had been held. The minutes of these meetings were available for inspection. There was evidence in the minutes that suggestions made had been responded to. Weekly health & safety checks of the premises were documented. Safety inspections had been carried out on the portable appliances, gas installations, lift and hoists. The five year electrical installations safety inspection had been done (1/3/06). Windows inspected had been fitted with window restrictors. The fire risk assessment had been updated. Fire drills and fire training had been documented. One of the drills had been carried out after dark. The weekly fire alarm tests had been carried out and evidence of this was provided. The inspector noted that one fire alarm test (for the previous week) had not been documented. This was discussed with the manager and administrator. The fire alarm was promptly tested the same day and found to be in working order. A requirement is nevertheless, made for the fire alarm to be tested and documented weekly. Significant incidents had been promptly reported to CSCI via Regulation 37 report forms. The home had a current certificate of insurance. The accounts of three residents whose money were kept by the home were examined and noted to be satisfactory. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 24 The inspector noted that valuables had been deposited in the home’s safe. The home had a policy on the storing of valuables in the home. The inspector however, noted that residents or their representatives had not always signed for valuables deposited. This was discussed with the administrator and manager. The administrator responded promptly and requested that a relative who was present sign for an item deposited in the safe. A requirement is nevertheless made for all items deposited by residents to be signed by them or their representatives. This is required to provide evidence and details of ownership of items deposited. The home had an effective quality assurance and monitoring system. A recent consumer survey report of the services provided by the home was available for examination. This was positive and the satisfaction level was high. Acacia Lodge DS0000010392.V343503.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 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 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 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 4 X 3 X 2 X X 2 Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no 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) The registered person must provide evidence that residents (or their representatives) have been consulted regarding their care plans. This evidence could be in the form of signed care plans. 2 OP38 23(4) The registered person must ensure that the fire alarm is tested weekly and documented. 3 OP35 12(1) 13(6) The registered person must provide residents (or their representatives) with the opportunity to sign for items or valuables deposited in the home’s safe. 01/10/07 Requirement Timescale for action 30/10/07 13/10/07 Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 27 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 OP12 Good Practice Recommendations The registered person should review the provision activities and ensure that residents are provided with appropriate daily social and therapeutic activities. Acacia Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Lodge DS0000010392.V343503.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!