CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE
Acacia Lodge Nursing Home 15 Wellingborough Road Irthlingborough Wellingborough Northants NN9 5RE Lead Inspector
Judith Roan Unannounced Inspection 11th April 2006 10:00 X10029.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 Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. 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 Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Acacia Lodge Nursing Home Address 15 Wellingborough Road Irthlingborough Wellingborough Northants NN9 5RE 01933 651660 01933 652948 thedurrantm@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited 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) Mrs Diane Pryce-Dyer Care Home 40 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (5), of places Physical disability (18), Physical disability over 65 years of age (18), Terminally ill over 65 years of age (5) Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Acacia Lodge is a home situated on a main route within the small town of Irthlingborough in Northamptonshire. The home is within walking distance of Irthlingborough Town Centre where community resources include churches, shops, pubs and restaurants. The home is owned by BUPA Care Homes Limited and is registered to provide both Nursing and personal care for service users with a variety of needs, the majority of which are over 65 years of age. Accommodation to the service users is provided across two floors, there are 30 single rooms and 5 double rooms with the majority providing en suite facilities. The home has four lounge areas, one of which is a designated smoking area and a dining room on both floors. Access to the first floor of the home is by passenger lift. Fee Levels at the home range from £450 - 600 Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting five residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Prior to the visit the inspector spent time collating within the ‘record of inspection’ information from notifications, an application to register a new manager and the outcomes from a monitoring visit on 24 January 2006. This visit was to establish how the action plan provided by the home to meet the required improvements from the previous inspection had been implemented. The inspection took place during the morning and afternoon, over a period of 9.5 hours and was carried out on an unannounced basis. What the service does well:
The atmosphere in the home was friendly and relaxed, and staff were welcoming. The complaints policy and procedures is easy to access with a copy being located in all bedrooms and reception area of the home. There are good records kept of all complaints. The complaints policy is a corporate one and is not specific for Acacia Lodge. Staff demonstrated a good understanding of the residents’ needs and were seen to have good communication with residents. A varied and interesting menu is planned, which enables resident to have a choice. Residents that require a soft have the meals served in an appetising manner with each component liquidised separately. Staff were supporting residents with meals if required. Residents were very pleased with the meals and the portions offered. Residents were able to move around the home easily within its confines. The home has graphic signage displayed to support residents with dementia with access to lavatories, bathrooms and their own personal room. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 6 There is evidence that health care needs are being met with good access to heath care professional. Medication systems ensure that residents’ needs are met and protected. Residents live in a home that has a good standard of cleanliness undertaken by a dedicated staff team. Laundry is well maintained and residents said that they were happy with the level of this service. Systems are in place to ensure that residents are safe when using equipment in the home. Wheelchair maintenance and cleaning is one of several checks undertaken by the maintainer on a regular basis. What has improved since the last inspection? What they could do better:
The homes manager needs to ensure that there is evidence that residents or if they are unable, an appropriate representative has been involved in the admission process, care planning and review. This was a requirement at the last inspection. At the monitoring visit and on this inspection there continues Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 7 to be no evidence within the files seen. This requirement is therefore unmet and is restated in this report. The pre-admission assessment tool should be developed further so that sufficient information is sought prior to admission to enable an initial care plan to be developed to support residents identified needs. There is a need to continue the work in establishing information about residents’ lifestyle histories, to enable individualised activities to be developed. The Commission for Social Care Inspection have received the required comprehensive and detailed refurbishment and redecoration plan that was a requirement made at the last inspection. However the registered manager has informed the Commission of a planned extension to the communal sitting rooms on both floors. The proposed date for commencement is in June 2006. The management are aware of the actions and precautions that need to be taken to protect the residents whilst this work is undertaken but need to produce risk assessments to ensure residents safety during this period of work. Redecoration and replacement of furnishings and fittings are to be conducted after the building works are completed. 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 Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)1,2,3,4,5 & (YA) 2 Quality in this outcome area is adequate. The homes admission procedure does not meet all of the above outcomes for residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A copy of the service users guide and terms and conditions are placed in every residents’ room. However the guide needs to be written in a manner that can be easily understood by the reader. This was a recommendation from the last inspection that has not yet been achieved. The Registered Manager did indicate during a monitoring visit in January that the guide is to be reviewed in the near future following the appointment of a new administrator. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 10 The pre-admission assessment tool does not enable full information to be gained prior to admission so an initial care plan to be developed The Registered Manager confirmed at the monitoring visit that the existing pre-admission assessment format is currently being reviewed. In the interim the existing form is being adapted at each assessment to ensure that adequate information is recorded regarding the individual’s specific needs. The home was also not sent assessments of need and care plans by Care Managers prior to admission. These often arrived several weeks later when the review of the care was undertaken. No contracts were available on individual files case tracked. In discussion with the Registered Manager individual contracts for care purchased from Northamptonshire County Council do not arrive until several weeks after a residents’ admission into the home. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): (OP)7,8,9,10 & (YA) 6,9,16,18,19,20 Quality in this outcome area is adequate. A competent staff team meets Resident’s health and personal support needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A sample of residents were selected for case tracking purposes and the individual plans of care evidenced a marked improvement. Residents were seen to have their individual needs recorded which provided staff with detailed instruction as to how those needs were to be addressed. Health needs were seen to be referred promptly to health care professionals when required.
Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 12 Case tracking identified that individual plans of care are developed according to the residents assessed needs and that these are reviewed on a monthly basis. However there continues to be no evidence that the resident, or if they are unable, an appropriate representative is involved in either the care planning process or the review. Resident’s individual plans of care evidenced that appropriate risk assessments are conducted in relation to the prevention of falls, nutritional vulnerability, pressure and movement and handling. Appropriate instruction was provided to staff to enable the risks to be reduced or managed. It was noted in reading one residents file that there had been a loss of weight sine their admission. This resident was also observed to leave their food at lunchtime. The care plan indicated that the resident should be offered finger food throughout the day. See standard 15 It was recommended at the last inspection that individual plans of care evidence the equality and diversity needs of residents. Records seen showed that residents’ needs are noted. Several residents were supported in following their religious beliefs. Medication systems within the home ensure that residents are kept safe. Good recording systems ensure that medication is not over stocked. All medication is checked in with amount recorded. A contract to dispose of medication is in place at the home and is working well. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)12,13,14,15 & (YA) 7,11,12,13,14,15,17 Quality in this outcome area is adequate. Activities were not seen to reflect the individual needs of residents. Residents are supported well to maintain contact with families and the local community. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Individual plans of care provided some evidence that residents are supported to achieve their expectations, preferences and choices. Improvements to the individual plans of care include a section for residents’ personal routines and preferences to be recorded. In addition further work is ongoing to establish lifestyle histories to enable individualised activities to be developed.
Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 14 A newly appointed activities coordinator is beginning to plan both group and individual activities. However as they were on leave at the time of the inspection it was not possible to identify what progress had been made since the last monitoring visit. In the afternoon of the inspection several residents from both floors in the home played bingo. In addition the organisation have developed a staff-training programme designed to improve the experience of residents, individuality and service improvement. One resident spoken with attends a local day service for people with a physical disability on three days a week and also the PHAB club one evening a week. Residents are encouraged to have hobbies that they can continue in their bedrooms. The refurbishment due to commence in June will extend the garden area where they will be an opportunity for residents with an interest in gardening to take an active role. Families are made very welcome and according to one relative they were highly satisfied with the support their family member was receiving. There was always a member of staff on duty that could give them information and they were kept informed about them care at the home. Meals being served at the home can be taken in one of the two dining rooms or on a tray in the residents’ room. There is always a choice of two dishes at lunch and teatime. The inspector noted that residents were supported to eat their meals if required with staff being attentive to individual needs. If a service user does not wish their main meal at lunchtime it is available at a later time in the day. One resident was seen to leave their food and staff spoken with said it occurred most days. The care plan indicated that this resident was to be offered finger food throughout them day to compensate for their poor eating at meal times. On speaking with staff they were not aware of this. Residents requiring a soft or special diet are catered for well. One gentleman with an Asian cultural history had meals specially suited to meet his tastes. All food was served attractively and in a pleasantly maintained dining area. Whilst being conveyed to the dining room food was covered. All staff wore aprons over their care uniforms to maintain hygiene standards. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 15 Complaints and Protection
The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)16,17,18 & (YA) 22,23 Quality in this outcome area is good. Residents can be assured that they will be listened to and protected by work practices within the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents and a relative spoken with during the inspection were aware of the complaints procedure and felt confident that their views were considered important and acted upon. The home has access to a corporate complaints policy, which specifies specific timescales for acknowledgement of and the investigation of complaints. In addition this document also specifies the processes involved at different levels of the organisation. In addition the organisation have produced a complaint leaflet, which is available to residents, their representatives and is included within the service Users Guide. This leaflet provides appropriate ‘user friendly’ guidance and the facility to anyone wishing to make a complaint. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 16 Complaints received by the home are now managed in accordance with the corporate policy. The Protection Of Vulnerable Adults policy was reviewed and found to have had the required amendments included. Staff spoken with were aware of the abuse awareness and whistle blowing (Sharing their concern of abuse with a manager) policies held at the home, with several having received training recently. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)19.20,21,22,23,24,25,26 & (YA)24,30 Quality in this outcome area is poor. The environment is maintained to a good standard of cleanliness and is safe. The internal decoration remains poor. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Commission for Social Care Inspection have received the required comprehensive and detailed refurbishment and redecoration plan specified at the last inspection.
Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 18 This includes details of a planned extension to the communal sitting rooms on both floors. The expected commencement is early June and will include the provision of a secure garden area that residents with a dementia will be able to access. The management are aware of the actions and precautions that need to be taken to protect the residents whilst this work is undertaken. Redecoration and replacement of furnishings and fittings are to be conducted after the building works are completed. Risk assessments are required to be completed and submitted to the Commission for Social Care Inspection to ensure that residents are protected during the refurbishment period. The home was found to be clean and hygienic maintained by a dedicated housekeeping team who also undertake the laundry. Residents said that their laundry was well done and always came back ironed. Household cleaning products and toiletries that could harm residents are securely kept with staff having full awareness of hazards within the workplace. Regular health and safety training takes place at the home. The home has a range of lifting equipment to assist with transfers from wheelchairs and for bathing. This equipment is maintained on a regular basis and to the required standard. Hygiene contracts are in place to deal with waste material at the home and to service equipment. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)27,28,29,30 & (YA)32,34,35 Quality in this outcome area is good. Work practices within the home meet the needs of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staffing levels within the home were seen to meet the needs of residents throughout the day. Needs were promptly supported by care staff that undertook their duties in a friendly and caring manner. Resident’s confirmed that staff were always respectful and met their needs competently. Staff were in the main knowledgeable about the needs of residents and demonstrated that they understood their role. Staff files demonstrated that a robust recruitment process is in place, with all appropriate checks being undertaken. These include references, criminal record
Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 20 bureau disclosures and for nursing staff registration with the Nursing and Midwifery Council. New staff undertake a full induction programme that is followed by further in house training. Several staff are presently undertaking National Vocational Qualifications in care at Level two. The organisation has an ongoing training programme that staff can apply for. Since the last inspection several staff have received traning in abuse awareness and more are booked to attend in the future. Staff spoken with showed that their knowledge had increased since the training and that they were more aware and confident in reporting concerns. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (OP)31,33,35,36,38 & (YA)37,39,42 Quality in this outcome area is adequate. Management practices within the home ensure that the home is run in the best interests of residents where their views are listened to and acted upon. Residents are protected by good record keeping and safety checks. This judgement has been made using available evidence including a visit to the service.
Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 22 EVIDENCE: The quality assurance system undertaken by an independent organisation produces a report that is published. Residents and their relatives are asked to complete a questionnaire, the finding are analysed and used to develop the service in the future. Other internal audit checks are used in specific areas like catering, health and safety to ensure that action can be taken to meet the organisation quality standards. The inspector found that the homes maintainer undertakes regular system checks on the fire system and ensure that all gas, electrical and water equipment is serviced are required. Full records are kept and were found to be easily accessible. Residents’ finances and the records on this inspection were not checked as it was not possible to access these. It is recommended that the Registered Manager reviews how these can be accessed outside of administrative hours. Supervision was not seen to occur as frequently as recommended under the National Minimum Standards and needs to be addressed. One new member of staff had not received supervision since the commencement of their employment. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 23 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 2 2 3 2 4 3 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 ENVIRONMENT Standard No Score 19 2 20 3 21 3 22 3 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 2 37 2 38 3 Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 24 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. 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. 2. 3. Refer to Standard OP1YA1 OP2 YA5 OP3YA2 Good Practice Recommendations The Service User guide should be written in a manner that can be easily understood by the reader. Care files need to contain a contract signed by the resident and or their representative. The pre-admission assessment tool should be developed further so that sufficient information is sought prior to admission to enable an initial care plan to be developed. Information should be gained from the funding authority or referring agency prior to admission. Each resident must be involved in the development and review of their care plan. There must be written evidence to evidence the involvement of the resident. This was a requirement at the previous inspection on 18/10/2005 and has not been met in total. The manager needs to ensure that all staff members receive supervision at least six times per year.
DS0000029163.V288713.R01.S.doc Version 5.1 Page 25 4. OP7YA6 5. OP36YA36 Acacia Lodge Nursing Home 6. OP37YA40 YA41 It is recommended that the Registered Manager review how residents’ finances and records can be accessed outside of administrative hours. Acacia Lodge Nursing Home DS0000029163.V288713.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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