Inspection on 07/10/05 for Acacia Lodge

This inspection was carried out on 7th October 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 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 Kathy Martin Announced 7 October 2005 10:00 th 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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 452855 Metro Care Homes Ltd Carol Evans CRH N 36 Category(ies) of OP - Old Age - 36 registration, with number LD - Learning Disability - 1 of places Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 5th May 2005 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection this year. The home was last inspected in May 2005. All the key national minimum standards for older people have now been assessed over both inspections. The inspection was announced which means that the residents and staff were made aware that the inspector was coming to the home. The inspection took place in the morning. The manager was present and contributed to the inspection by providing information from the preinspection questionnaire and also in discussions with the inspector. The residents were observed in the various areas of the home attending to their own routine day-time activities, some finished breakfast and were getting ready for the day and others in the different communal areas chatting to each other and to the staff. The manager had returned from a planned sickness leave. However the deputy manager who had commenced work in May 2005 (at the last inspection) has now left the service and is working as manager in another Metro care home. There is a second deputy in place as the home runs with two deputy managers. The inspector looked at records, spoke with the staff, the manager and also several residents on the day. The building was also toured. The inspector wishes to thank them all for their hospitality and co-operation in producing this report. The home was running efficiently and there were sufficient staff on duty to attend to the residents’ care. The home was clean and tidy and had a homely feel. A few residents/ relatives also returned completed questionnaires to the CSCI. The completed boxes indicated that their experience of the home was positive. What the service does well: The home offers plenty of meaningful activities for the residents who stated that they liked what was offered to them. The food is reported as very good. The staff have a good rapport with the residents and the relatives. Interactions observed on the day indicated that there was a positive atmosphere that Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 6 encouraged and supported residents to maintain independence and also to mingle with each other. 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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) EVIDENCE: This section was covered at the previous inspection. There had been no changes in the assessment process for residents coming into the home. The prospective residents are still offered a range of information relevant to their placement. The comments made at the previous inspection remained current. Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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 standard(s) 9 and 10 The home had a comprehensive medication procedure for the management of medication. The home operated in a manner that was sensitive to residents needs for privacy and actively promoted this practice in the way it runs. EVIDENCE: Standard 9: The medication policy and procedures were looked at and these were explicit. The home received a pharmacy inspection carried out by the community pharmacist. The report stated that all was in order and there was no recommendations for improvement suggesting the home’s procedures were followed appropriately. The inspector inspected the storage room and medication was clearly labelled and stored in their respective places. The medication records were completed on time and had no unexplained gaps. The registered nurses were the only staff who dealt with medication and all have a medication update regularly. The deputy manager took an extended responsibility to ensure medication practices were in order. The recent medication disposal/ returns legislation were implemented meaning that they no longer get returned to the dispensing Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 10 chemist but have to wait for collection from external contractors to be disposed of safely. Standard 10: The home encouraged good principles of care including respecting privacy. The new staff have to work alongside a trainer carer who re-enforces those principles whilst closely monitoring staff practices. This enables any issues to be rectified at source. There are currently 10 residents who have to share their bedroom (5 shared bedroom accommodating 10 residents). Screens are provided for privacy. All residents who share bedrooms have made an informed choice to be accommodated with another resident. Some are offered a choice to move to another single bedroom when one is available. There are regular reviews that are undertaken at least once a year to discuss their placements. The home has 3 lounges and offers plenty of areas for private meetings with relatives or friends. Residents wear their own clothing and are able to receive their guests or visiting professionals in private. A telephone is available at their request and residents are responsible for the costs of private telephone hire. However they can receive calls in the home in private. Staff are instructed to knock on the doors before being invited by the residents to enter. Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 The home employs an activities coordinator who is responsible to ensure all residents are encouraged to participate in recreational activity and keep in touch with the community, family and friends. Residents are encouraged to maintain control over their lives and be independent. The home offers a good range of meals provided internally by the catering department. EVIDENCE: Standard 12, 13 and 14: There is an activities organiser who works 5 days a week. A weekly plan is pinned on the notice board. The organiser obtains residents’ preferences in advance and includes outside agencies to provide activities and entertainment. For example: bingo, keep fit, outings to the museum and community events. Other examples of internal activities include newspaper reading, arts and crafts, birthday celebrations, parties and barbecues. Many residents quite like to chat to each other. This was evident during the visit to the home. The staff reported that the weekends are usually a relaxing time for residents to receive visitors as this is usually a preferred time for visitors and there are no planned activities booked on those days. However staff would do one to one sessions and have discussions, board games with residents during the weekends. Music and television also provides some entertainment. It was pleasing to see that Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 12 due to the lay out of the home, there are quieter areas where residents can also sit without having to hear the television or the music if they chose not to. Residents go out with relatives and friends and receive visitors as they wished. Staff would facilitate keeping in touch via telephone calls or written communication on behalf of residents to their request. It is acknowledged that a lot of residents who live in Acacia Lodge are also very physically frail and are not able to go out into the community by themselves. They are often dependent on visitors and staff providing the link with outside and rely on television or newspapers to keep informed. The home would provide transport to shops, hairdressers and visits to the hospital appointments if needed. Standard 15: All meals are prepared internally. There is a good breakfast including cooked options, lunch and dinner, which offered a choice. The meals were varied regularly and the meals were wholesome. The residents spoken with said they liked the food they were given and made special mentions to being spoilt by the cook by the numerous tempting desserts. The home can cater for vegetarian diets and also for other special diets. Snacks and beverages can be obtained any time day or night. There are regular tea/ coffee rounds and drinks of water and squash are available at all times for residents to keep hydrated. Staff were observed reminding residents to drink which was good practice. Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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 remained pro-active. The home has procedures for dealing with abuse. EVIDENCE: 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 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) This section was assessed during the last inspection and comments made then remained relevant. EVIDENCE: Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 15 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) 29 The home does have policies and procedures to deal with the recruitment of staff and which should, if followed, ensure residents’ protection. However on this occasion, there were shortfalls in the contents of the staff files. Not all staff had contracts of employment. EVIDENCE: The staff files needed to be maintained in accordance with the regulations to include all relevant identification copies such as passports, and a recent photograph. The files inspected had several documents that were required but they were not maintained in a consistent manner. A requirement was made to this effect to ensure residents’ protection. Additionally it was not possible to detect the exact job descriptions of the staff employed in the absence of this document and a contract on their files. The home must provide contracts/ job descriptions for all staff employed by Metro Care. The staff files would be sampled again during the next visit to check on compliance with these regulations. Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 16 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) 33, 37 and 38 There is evidence to suggest that the home took residents’ experience and welfare seriously and aim to provide a reasonable and happy environment. The documentation was overall well maintained and the CSCI is kept regularly informed of accidents and any untoward events. The home has policies and procedures to deal with health and safety matters. EVIDENCE: Standard 33: The home welcomes feedback from all the visitors and the residents. There are consistent efforts from both the management and the care staff to encourage residents to take part in the running of the home. The residents and their families are regularly consulted when changes are planned. There are opportunities offered for one to one discussions with the manager. The management style is proactive. Staff met regularly to discuss their involvement in the home and there is much teamwork observed. Staff Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 17 appeared encouraged to suggest changes if they thought of any ideas that would benefit the residents. Under Standard 37: The general documentation for care and the management of the home were maintained in good order and were clear and regularly reviewed. However there were issues relating to the staff files. Please refer to the comments under Standard 29 regarding documentation on the staff files that needed to be maintained in accordance with the regulations. The home must provide contracts/ job descriptions for all staff employed by Metro Care. Under Standard 38: The home has policies and procedures to ensure health and safety practices for staff and residents. There are regular maintenance checks internally and externally. The home is well maintained and is in good decorative order (due to recent refurbishment) The equipment is serviced regularly including fire, disability, bathroom and kitchen equipment and appliances. Breakages are reported and repairs are undertaken promptly. All accidents and incidents are reported appropriately and care managers, next of kin and the CSCI are kept informed under Regulation 37. The CSCI does not currently receive Regulation 26 visits reports as required by this regulation. This is a requirement as the registered provider is not involved on a day-to-day basis in the home. It is acknowledged that he does visit the home very regularly and it is reported that he has an excellent rapport with the staff, is supportive and proactive. However the visits must be unannounced on a monthly basis and offer an overview of how the home is operating. A copy of this visit must then be sent to the registered manager and to the CSCI. Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 18 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x 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 3 x x x 2 3 Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 19 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 29, 37 Regulation 19 Requirement The staff files needed to be maintained in accordance with the regulations. The home must provide contracts/ job descriptions for all staff employed by Metro Care. Commence Regulation 26 unannounced monthly visits to the home and provide copies of the report form the visits to the registered manager and the CSCI Timescale for action 05/12/05 2. 3. 29, 37 33 19 26 05/01/06 05/12/05 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 Good Practice Recommendations Acacia Lodge h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 20 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 h09-h58 s53851 Acacia Lodge v241216 071005 stage 2.doc Version 1.40 Page 21 - 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. 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