Inspection on 03/05/07 for Acacia Lodge

This inspection was carried out on 3rd May 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 Lodge 15/06/06

Acacia Lodge 07/10/05

Acacia Lodge 05/05/05

Acacia Lodge 13/09/04

Acacia Lodge 08/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

The Shelley

Thorndene

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Acacia Lodge Rookery Road Staines Middlesex TW18 1BT Lead Inspector Kenneth Dunn Unannounced Inspection 09:30 3rd May 2007 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 DS0000053851.V338916.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. DS0000053851.V338916.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 acacia@chessbroadband.co.uk Metro Care Homes Limited Care Home 36 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (36) of places DS0000053851.V338916.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 15th June 2006 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 £549 to £750 per week. Additional charges apply for hairdressing, chiropody, dental and ophthalmic services. DS0000053851.V338916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI. The visit was carried out by Mr K Dunn, regulation inspector and included a tour of the premises, informal interviews with staff and the people who use the service (a request has been made by the people who use the service to be referred to as residents), and a review of documents and records. Acacia Lodge is operating without a registered manager, the previous registered manger resigned a short time ago. A recently appointed manager who has the direct responsibility for the home, residents and staff is covering the day-to-day management. The responsible individual is however very hands on and is available to the manger at any time. The visit commenced at 10:00hrs and finished at 15:00hrs. The inspector would like to thank the manager Ms R, A Smith and Mrs R, Tharani operations director, the staff, Residents and others for their contribution. What the service does well: The home has an experienced manager who is now providing management stability, leadership and direction to the staff team. During discussions a member of a resident family sated that this manager was “one in a million”. Meals at the home are good and offer variety, choice and healthy eating options. During discussions a resident commented ‘‘the food is very good’’ and “there is always an option if I do not like what is being offered”. The home values equality and diversity and staff have value-based training in privacy, dignity, rights and respect. Care plans reflect the unique needs of individual residents. It is recorded on a visitor’s questionnaire ‘‘it is now a happy place and you look after everyone well’’. The home has good procedures for needs assessment and care planning is based on best practice. It is recorded on a visitor’s questionnaire ‘‘we are glad we chose this home’’ and during discussions a resident commented ‘‘staffing is acceptable’’. Family links are promoted with flexible visiting times. During discussions a resident stated ‘‘my family visit me, they just turn up’’ and feed back received from a visitor’s questionnaire ‘‘we can stay for as long as we like and talk for as long as we like’’. Activities are organised with opportunities for all residents being built into the programme. DS0000053851.V338916.R01.S.doc Version 5.2 Page 6 Quality assurance at the home is now being carried out the most recently completed questionnaire indicated that the resident and their families are happy with the care being offered at Acacia Lodge. The home had a good complaints procedure and a review of records confirmed no complaints were recorded about the home. The inspector noted the CSCI had no record of safeguarding adult matters pertaining to the home and during discussions a service user commented ‘‘I get on with staff very well’’. On the day of the inspection the home was clean, nicely presented and free from mal odour. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000053851.V338916.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 DS0000053851.V338916.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): Standards 3 & 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing the care needs of prospective residents are good. The service undertakes a full need assessment to assure all potential residents needs can be met at Acacia Lodge. EVIDENCE: The manager stated that all potential residents of Acacia Lodge are only admitted into the home after a full assessment of needs has been completed. A review of records confirmed the home had a policy on admission and a care needs assessment which covered personal care, health needs and social support. The inspector noted the manager had responsibility for assessing the needs of prospective residents. The assessments sampled during the visit were comprehensive and offered a clear picture of the needs of the person being assessed. The manager confirmed the home does not offer intermediate care and this standard was not assessed. DS0000053851.V338916.R01.S.doc Version 5.2 Page 9 DS0000053851.V338916.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 & 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are well defined setting out the personal care, health needs and social support required by each individual. The arrangements for health care ensure the residents have access to all healthcare services. The medication policy in operation is well designed and the day-to-day medication practices safeguard the welfare of residents. The arrangements for privacy and dignity are good ensuring the residents are treated with respect and their right to privacy upheld. EVIDENCE: The manager stated that all resident have individual care plans, which included risk assessments in the areas of mobility and prevention of falls. A review of records confirmed care plans were based on best practice, they all appeared to be regularly reviewed, dated and signed by staff to reflect the changing needs of the resident. DS0000053851.V338916.R01.S.doc Version 5.2 Page 11 Information returned to the CSCI from residents and their representatives confirmed that they were satisfied with care received from staff at the service. The service had arrangements for meeting the health care needs of the residents with input from health care professionals as required. A review of records confirmed service users were registered with a local GP (General Practitioner) and had access to chiropody, dental and optical services. The inspector noted the home had risk assessments tools for pressure sores and nutritional screening. The medication policy is robust and designed using best practices methods. A review of records confirmed medication record sheets were dated and signed by staff and a record of medications received by and disposed of was kept to prevent mishandling of medications. Observations confirmed the home had adequate storage of medications and staff had accredited training in medications to safeguard the welfare of service users. However the service does not offer the residents the opportunity to control their own medications. The inspector requires that the manager undertake detailed risk assessments for all residents who may or may not be able to control their own medications. The manager stated the home had a policy on privacy and dignity and staff have training in privacy, independence, rights and respect reflected in the staff induction programme. Observations confirmed staff addressed service users by their preferred names and knocked on doors before entering bedrooms and bathrooms. On family member of a resident commented that “my mother likes to keep herself private if she want to and staff are willing to leave her at peace”. DS0000053851.V338916.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 & 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities at the home are designed to fulfil the social, recreational, religious and leisure needs of the residents. The arrangements for community contact and promoting family links are well established. Policies and procedures are in place to enable the residents to exercise choice over their own lives. Meals are predominately homemade and of a high standard they offer variety, choice and healthy eating options. EVIDENCE: The service had a written programme of activity and events these were displayed on the resident’s notice board. The inspector noted activities included gentle exercises, bingo, and concert and theatre outings. The inspector noted the home had arrangements for meeting the religious needs of the residents. The manager stated that all residents currently living at the service are Christians. In the event of someone being admitted from a religious group other than Christian the home would make every effort to ensure that they can practise their religion without prejudice. The manager DS0000053851.V338916.R01.S.doc Version 5.2 Page 13 stated that a Roman Catholic priest visits the service twice a month to offers mass and they have just rearranged for a Church of England priest to recommence services at Acacia Lodge. The manager stated the home had a visitor’s policy with information in the statement of purpose and service user guide. A review of records confirmed relatives visited the home and residents were able to receive visitors in the privacy of their bedrooms, if necessary. During the visit over 14 visitors came to service to visit their relatives. One family member spoke very highly of the service his wife received from the home, and how they always make him feel very welcome no matter what time he comes. A comment card received by the CSCI stated that “we can just turn up’’ and another one stated that ‘‘we can stay for as long as we like and talk for as long as we like’’. The home employees a full time cook to plan and prepare meals. A review of menu plans confirmed meals offered variety, choice and healthy eating options. On the day of the visit the residents had homemade country pie and assortment of fresh vegetables, followed by a pudding or fresh fruits. Observations confirmed meals were nicely presented and mealtime was relaxed and unhurried with hot and cold drinks available. The cook informed the inspector that the where possible she will only use fresh products to ensure that her kitchen only produces good quality meals. In discussions with residents the majority were very happy with their meals and had nothing but praise for the cook. DS0000053851.V338916.R01.S.doc Version 5.2 Page 14 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 & 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints process is user friendly and designed to allow residents and their relatives feel confident that their complaints will be listened to and acted upon. The service has robust arrangements for safeguarding adults. EVIDENCE: The manager stated the home had a comprehensive complaints policy. The policy is detailed within the statement of purpose and service user guide in addition a copy is on display on the resident’s notice board. The complaints record was sampled and confirmed that no complaint have been recorded since the last inspection by the CSCI. During discussions a resident commented ‘‘yes, I am happy here I have no complaints’’. However one comment card returned to the CSCI from a family member of a resident stated that although they had no complaints they were not fully aware of the process they would have to go through if they wanted to raise an issue. The home had a policy on protection of vulnerable adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed the home had a whistle blowing policy. A review of information confirmed no adult protection matters were recorded about the home since the last inspection by the CSCI. DS0000053851.V338916.R01.S.doc Version 5.2 Page 15 DS0000053851.V338916.R01.S.doc Version 5.2 Page 16 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 & 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are homely and comfortable. The arrangements for hygiene control are good ensuring the home is clean and hygienic. EVIDENCE: The general environment of the home meets the individual and group needs of the residents. The home was clean and relatively free from mal odours. However there are areas where the environment was not of a suitable standard. The main areas of concern were the limited usable space in the assisted bathrooms. The manager informed the inspector that the inability to use a hoist in all but one assisted bathroom had reduced the facilities greatly. The service has plans to introduce an assisted shower room but there is no time scale for its implementation. The paintwork in several areas throughout the home was scuffed and marked and in need of remedial redecoration. The DS0000053851.V338916.R01.S.doc Version 5.2 Page 17 home has a basic maintance programme in place but there is no clear timescales for the completion of works carried out. A requirement has therefore been made in respect of these issues please refer to page 24 of this report. DS0000053851.V338916.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff on duty and the skill mix meets the resident’s needs. The training of staff especially NVQ level 2 in care continues to improve. The residents are protected by the homes recruitment policy and practice. The home has regular training for all staff making them competent to do their job. EVIDENCE: The manager stated the home had adequate staffing levels that were calculated using an approved formula and the inspector noted the manager had responsibility for planning the home’s duty roster. The home is committed to staff training and development. The service accesses a variety of training opportunities all staff are and a review of records confirmed a The home had a policy on staff recruitment and the manager confirmed prospective employees are vetted before being employed by the home. The staff recruitment files contained completed application forms, written references, statement of terms and conditions, training records, CRB (Criminal Record Bureau) disclosure information, a recent photograph of the employee and staff have copies of the GSCC (General Social Care Council) code of DS0000053851.V338916.R01.S.doc Version 5.2 Page 19 practice to safeguard the welfare of service users. The inspector noted staff recruitment files were securely stored to promote confidentiality. The home had a policy on staff induction, an induction checklist and structured induction and foundation training. DS0000053851.V338916.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35 & 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for the day-to-day management of the home are good. The home has systems in place for assessing the quality of the service it provides and to ensure the home is run in the best interest of residents. Policies and procedures are robust and designed to safeguard the financial interests of individuals living at Acacia Lodge. The arrangements for health and safety are good promoting safe working practices. EVIDENCE: DS0000053851.V338916.R01.S.doc Version 5.2 Page 21 The home has an experienced manager who is working towards the RMA (Registered Manager Award) qualification and provides management stability, leadership and direction to the staff team. The inspector noted the home had a management structure with clear lines of communication and accountability and during discussions a member of staff stated ‘‘management is good, fine and I have no problems’’. On a tour of the premises the manager had a warm welcome to all of the residents and in turn they appeared to respond very warmly to her. One visiting relative sated that she is “one in a million” while other visitor gave and received very warm welcomes as they came into the home. The manager is not yet registered with the CSCI but has over 42 years experience of care provision both as a registered nurse level 1 and as a manager of care home for Older persons. The inspector was informed that the documentation has been prepared for the registration of the manager and that she was awaiting one last item prior to making an application. The home had a policy on quality assurance the management regularly hold meetings with residents and have used questionnaires to obtain feedback about the home. The inspector noted the home had a report dated January 2007 the findings indicated a high level of satisfaction about the home and the way it is being operated. However the overall layout of the questionnaire appeared very confusing and overly complicated. During discussions with the responsible individual it was felt that the quality audit form could be redesigned to allow all residents and or their family members participate fully in any new audits of the home. The responsible individual has acted on the recommendations made by the CSCI and policies and procedures have been revised and updated to reflect changing legislation and good practice. The home had a policy statement on money and valuables and the manager confirmed relatives have responsibility for the residents’ money. The inspector noted the manager did not act as appointee and relatives safeguarded the financial interests of service users. The home had a policy on health and safety and staff have training in health and safety, fire safety, food hygiene, infection control and other relevant and appropriate training. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products stored in a locked cupboard to promote safety. DS0000053851.V338916.R01.S.doc Version 5.2 Page 22 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 3 8 3 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 2 X X X X X X 2 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 X DS0000053851.V338916.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP19 Regulation 13(2) Schedules 3.3 (I&k) 23 (2) (b) (d) Timescale for action All residents must be assessed to 03/07/07 ensure that they can or cannot handle their own medication. The registered person must 03/07/07 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. A quality audit tool must be developed that will allow all residents and their representative to take part in the process. 03/07/07 Requirement 3 OP33 24 DS0000053851.V338916.R01.S.doc Version 5.2 Page 24 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 OP16 Good Practice Recommendations The Complaints policy should be available and fully explained to all residents and or their representatives. DS0000053851.V338916.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000053851.V338916.R01.S.doc Version 5.2 Page 26 - 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!