Inspection on 05/05/05 for Acacia Lodge

This inspection was carried out on 5th May 2005.

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 03/05/07

Acacia Lodge 15/06/06

Acacia Lodge 07/10/05

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 Kathy Martin Unannounced 05/05/05 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 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 s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Address Rookery Road, Staines, Middlesex, TW18 1BT Telephone number Fax number Email 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 459131 Metro Care Homes Ltd Carol Evans CRH N 36 Category(ies) of OP - Old Age - 36 registration, with number of places Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No more than one (1) service user admission per week and four (4) per month until a maximum of twenty-five (25) service users is reached. Further admission of service users thereafter will be subject to completion of the Action Plan/Management Schedule provided to the NCSC dated November 2003. Subject to the Action Plan requirements being met, the maximum number of service users may increase to thirty-six (36) incrementally, thereafter. No more than four (4) admissions in one month. 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. Date of last inspection 13/09/04 Brief Description of the Service: Acacia Lodge is a care home providing nursing care. It is situated in a residential road in Staines not far from the main town. Public transport is available to access the home. The home offers car parking and there are spaces for several cars on the actual road. This is a large detached property having undergone several refurbishment stages which now boasts a very pleasant dining room, a lounge and the managers office. The bedrooms have all been redecorated and refurbished with new furniture in the last 18 months. The home will be subject to further improvements subject to planning permissions in the future. The home is owned by Metro Care ltd who also runs similar other care establishments. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection this year. The home will receive another inspection before the end of March 2006. The inspection was unannounced which means that the residents and staff were not aware that the inspector was coming to the home. The inspection took place in the morning shortly after breakfast was over. The manager was present for the majority of the time. A new deputy was just in post and was receiving support from the manager and her colleagues to settle in the home gradually. The residents were observed in the various areas of the home, at some point walking around, being attended to by staff or in their bedrooms. The inspector had opportunity to speak to several residents who had very positive feedback about their home and all those spoken with stated that they liked Acacia Lodge and felt they were receiving good care. Comments included their satisfaction with the food, their carers and the environment. They enjoyed receiving visitors and also go out when able to. They felt that they were able to talk to staff when they had a problem. Not all residents knew about the CSCI. The home was being run in a generally organised manner on the day and the atmosphere was friendly but busy. Residents were encouraged to make conversation with the inspector and to share their experience of living in the home. The inspector looked at records, spoke with the staff, the manager and also several residents on the day. The inspector wishes to thank them all for their hospitality and co-operation in producing this report. What the service does well: The home had undergone some refurbishment and looked very pleasant. The décor is very homely and residents stated that they had comfortable rooms and surroundings. The care plans were generally well written. The rapport with the other care professionals who attend to residents was very good. The staff knew how to make use of their assistance to meet the needs of the residents. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 6 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. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 standard(s) 1, 3 and 6 The procedures for receiving new residents in the home is well managed on the whole and a good range of documentation is made available to prospective residents and all those who support residents to move in. EVIDENCE: The set of notes from two recent admissions were looked at. The manager also stated that she meets the residents in their own home/ hospital when she gives them the statement of purpose (which is a document with all the relevant details about the home and its facilities that it provides) and the home’s brochure. This allows a discussion about the home in general and about finding out the needs of the residents and to check if the resident’s needs would be met. There were several notes indicating that communication between relatives, doctors and other health care professionals like hospital staff had been involved in the placement. The residents were encouraged to visit the home on more than one occasion and have a meal with others prior to coming in. One service user spoke of the time they were admitted from hospital and the encouragement they had received from the staff and how they were made to feel at home. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 9 Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 The residents have a written care plan available, which details all their areas of needs. There were omissions on the daily care notes, which were not always as detailed in all care plans seen. Residents had access to a wide range of health care professionals to look after all their needs. EVIDENCE: 4 care plans were looked at. The documentation about residents’ areas of needs was well written in general. The registered nurses each looked after a group of care plans and regularly reviewed and updated them. All nursing assessments were in place. There were occasions when conversations between residents, visitors and staff could have been better recorded especially when there are difficult issues discussed. Residents risk assessments were in place indicating that they were encouraged to be independent and worked towards reaching achievable goals. One lady was working on the possibility of going on day trips home once her wheelchair is re-assessed and is ready for use. She was receiving help from the physiotherapist to achieve the goal of a home visit in the near future, which she told the inspector was what she most wanted. All residents have a doctor and were able to contact the surgery themselves or request the staff to do so. The doctor was present on the day of inspection. The manager reported that the staff and the doctors had a good working Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 11 relationship and it was always possible to get them to see residents dependent on their level of needs. Residents spoken with talked about visits to the dentist and opticians and others spoke about having chiropody and hospital appointments. This indicates that the staff were able to access all relevant professionals to ensure the residents were well cared for. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (this section was not inspected in full on the day and will be covered at the next inspection) EVIDENCE: Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 standard(s) 16 and 18 The home has a complaints procedure that is effective and used in most cases. Their approach to responding to complaints was pro-active. The home has procedures for dealing with abuse. EVIDENCE: During this inspection, the inspector discussed a complaint received from a relative. The staff were very helpful in providing the inspector with all the documentation and answers to questions asked. They also reacted positively to the complaint and suggested changes to how they did things to improve the way the home did things. The complaints procedure is offered to all residents and those who wish to be given a copy. The home also had several cards and letters they received in the past few months from respite clients and also residents’ relatives. The comments made indicated that they were very happy with the care they or their relatives received. Staff received training in the procedures for dealing with abuse and prevention of abuse. The training log was inspected and indicated that this training is considered mandatory (which means that the staff have to do it). Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 standard(s) 19 and 26 The home has undergone a programme of refurbishment in the last year, which has created extra homely and comfortable areas for residents to rest and engage in social activities. The home was kept clean and tidy and was pleasantly decorated. There are additional changes expected which will be subject to planning permission. EVIDENCE: The home looks very pleasant and residents were seen socialising with each other in taking meals together or chatting with each other and their visitors. The residents spoken with liked their bedrooms and stated that they had enough furniture and bedding. One resident enjoyed the radio whilst the other preferred watching TV until she was well enough to go to the lounge as she is having difficulties in using her wheelchair. The physiotherapist is helping with this. The home has a lift too which means residents can go on all floors. There is a large garden at the back and this is accessible. Staff can help those with mobility problems. The home is kept clean and tidy by a dedicated team. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 15 Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 a 30 The staffing has not changed in numbers since the last inspection and this means that there is a sufficient staff team of registered nurses and carers. All staff received training in relevant areas of their jobs for them to update and enhance their skills. EVIDENCE: The staffing structure allows sufficient staff on duty for each shift run on a rota to meet the different needs of the residents. There is a new deputy in post who commenced working in Acacia Lodge the week of the inspection. She was not working on her own for the first week of induction so she could spend time with the residents and getting to know them better. Training is offered to all staff. There is mandatory training which is what the home considers as very important such as health and safety, moving and handling, medication, First Aid, abuse awareness and basic food hygiene. Other training includes NVQ and discussions on various topics relating to good care practices. The home benefits from the training coordinator who works alongside the manager to support staff to train. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38 The home has policies in place for handling the finances on behalf of residents. There were no health and safety issues brought to the inspector’s attention. The procedures for all health and safety matters were available and staff knew about these via their training. EVIDENCE: Residents are encouraged from the start to remain as independent as they can. The residents are able to keep a small amount of cash with the staff that they can withdraw as they wished although they are encouraged to keep it themselves for total control. Many residents have relatives and legal representatives to help them with this. There were no health and safety issues noticed during the inspection. The home is well maintained and there is a handy man available to take care of any repairs. There are procedures to protect residents against any accidents in Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 18 terms of risk assessments in their care plans. The equipment is regularly serviced to ensure residents are moved safely and staff received training in all aspects of health and safety to help them do their jobs well. Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations Ensure all staff document their conversations with relatives and residents and especially when sensitive issues are discussed Acacia Lodge s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 © 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 s53851_Acacia Lodge_v224395_050505_St4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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