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Inspection on 13/07/05 for Acacia Lodge Nursing Home

Also see our care home review for Acacia Lodge Nursing Home for more information

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Once again it was observed that high standards are being maintained in this care home. The Manager confirmed that there have been no substantive changes to the home since the previous inspection. The inspector spoke to several of the service users and to visiting relatives. All spoke of a well run home with kind staff, good food and they all appreciate the beautiful setting in which they live, although on the day of inspection, in mid-July, it was a little too hot for some service users.

What has improved since the last inspection?

What the care home could do better:

This home continues to be self motivated and strives to maintain high standards throughout and so few requirements arise - but in this inspection some fire safety matters arose including the need to keep the side access clear and to insert magnetic door holders on fire doors that need to be kept open. It is also recommended that the home review window security throughout the home, especially on the ground floor.

CARE HOMES FOR OLDER PEOPLE Acacia Lodge Nursing Home 1 Stanhope Road Croydon Surrey CR0 5NS Lead Inspector Michael Williams Unannounced 13th July 2005 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 Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Nursing Home Address 1 Stanhope Road, Croydon, Surrey, CR0 5NS 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) 020 8688 8000 020 8667 1060 jag@irh-homes.com London Residential Healthcare Limited Mrs Ellen Teresa Ryan Care Home 30 Category(ies) of Old Age: 30 registration, with number of places Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4/4/05 Brief Description of the Service: Acacia Lodge is a nursing home registered with the Commission for Social Care Inspection to provide care for up to 30 Older People, aged sixty-five years and over. The property is a large detached property set in its own grounds amongst attractive, well-maintained gardens and close to a park. It is owned by London Residential Healthcare Limited. There is parking for cars to the front of the premises Accommodation is arranged over two floors with range of single and shared bedrooms. There is a lounge and dining room on the ground floor and toilets and bathrooms are located conveniently on each floor. The home has a variety of aids and adaptations required for the care of frail elderly people. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home’s philosophy, described in their Statement of Purpose, is “to provide a homely atmosphere and a high standard of nursing care”. There are both trained nurses and carers on duty twenty-four hours a day and a full time Activities Organiser leads a varied programme of activities. This was the second inspection to be conducted during the year 2005/06. During this and the previous inspection all the key standards affecting the comfort, safety and well being of service users have been assessed. Where key standards were assessed and found to have been met at the previous inspection they will not all be reiterated here if it appears that they continue to be met in the same manner as before. What the service does well: 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 Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 6 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 Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 7 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) 3 Service users have a comprehensive assessment carried out by the staff prior to their admission, which ensures that staff know and are able to meet service user needs. Service users, and their relatives, are involved in the identification of their care needs and planning how they would like them to be met in the care home of their choice. EVIDENCE: Evidence for this and other standards are much as they were before. A sample of service users case files were checked. Carers and nursing staff contributed in the assessment of this standard as did the manager (who is herself a Nurse). The service users and a visitor also assisted in confirming the findings. All prospective service users have a full assessment prior to admission and a trained Nurse undertakes these assessments. Each service user then has an individual and comprehensive care plan - drawn up in collaboration with the service user if this is possible or their relatives if it is not. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 8 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 All social care and health care needs are assessed prior to admission, these needs are then translated into care plans - which are reviewed and revised periodically. This ensures that service users will know that staff in the home are to able to meet their changing needs. EVIDENCE: Care plans are reviewed regularly, at least monthly to confirm they remain appropriate, and more comprehensively from time to time. Service users confirmed that their needs had been evaluated and put into care plans and monitoring formats including social contacts, dietary needs, medical conditions and treatment, skin care, manual handling (manoeuvring techniques) and so forth are monitored according to need. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 9 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 The home provides a very congenial setting which is comfortable, quiet and peaceful lifestyle for service users and enables the staff to assist and encourage service users to lead as fulfilled lives as they wish or their frailty allows. Service users are encouraged and given every opportunity to maintain contact with family and friends and the community. EVIDENCE: The service users state, and the inspector noted, that family and friends visit the home regularly. The visitors’ book confirmed this observation. Whilst there is no visitor’s room (for service users who share a bedroom) there are a number of rooms such as the office, which could be used for private meetings. Choices for service users are typical of this type of nursing home, for example choices may be made in respect of care planning, medication, meals, clothing, daily activities, religious observance and so forth. An activity programme is available for those service users who choose to take part and on the day of inspection a quiz was underway and was well attended although service users found the very hot day rather exhausting. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 10 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 18 The owners, manager and staff have a positive approach and attitude to service users concerns, complaints and suggestions, which enables service users to feel free to make observations, both positive and critical ones. Procedures and staff training for the protection of vulnerable adults have been introduced to ensure service users are protected from abuse. The manager confirms that all new staff do now have an up to date Criminal Record Bureau check. EVIDENCE: The record of complaints was checked on this occasion; and on previous inspections the suggestion and feedback book in the dining room has been checked; as this was an unannounced inspection no written feedback was received by the CSCI prior to inspection. Policies and procedures are in place for dealing with complaints and representations and for dealing with allegations of abuse. A training programme for staff is in place and staff confirmed they have completed National Vocational Qualification 2, which included training in respect of protection from abuse. A complaints leaflet is readily available in the home’s lobby. The home has a copy of the local authority’s procedures for dealing with the protection of vulnerable adults and staff are given training about this important matter as part of their induction. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 11 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 26 Service users live in a safe, well-maintained and comfortable environment. This is a purpose built care home and is subject to ongoing refurbishment. It was clean and tidy at the time of inspection and the staff were working hard to reduce the effects of a very hot and sunny day. EVIDENCE: As in the previous visit, the inspector toured the building including the ground and first floors, the garden and cellar. Service users offered their opinion about the premises – they think it a fine building with pleasing outlooks. The grounds are well maintained and looked most attractive; the veranda was a popular venue on the day of inspection. The building is in a good state of repair and the on-site maintenance person is available to deal with damage and breakages. There is a mixture of single and double rooms and many have ensuite facilities. The staff, including ancillary staff, receives training in health and safety including the control of chemicals, handling and manoeuvring service users and general matters of safety for service users. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 12 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 29 Staffing levels, staff training and support are in place and there is sufficient staff with the necessary skills to meet the service users assessed health and care needs . EVIDENCE: Staffing levels for existing care homes, including those that provide nursing care, must be no less than the guidance issued by the previous regulating body, the Health Authority. Nursing staff, Care staff and ancillary staff were within those levels on the day of inspection. A training programme is place and this provides a comprehensive schedule of induction and ongoing training for all staff. When this home was inspected earlier in the year not all new staff had undergone the required Criminal Records Bureau and Protection of Vulnerable Adults list checks [CRB and POVA], which could have compromised the safety and well being of service users, so a requirement was made to address this matter. The manager confirmed that all staff are now suitably checked before being employed in the home. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 13 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) 31 38 This is a well managed care home; the home has a competent nurse-manager and the owners are clearly dedicated to providing a high standard of care. Service users’ needs are a key consideration to the running of the home and their care and well being is seen as paramount. There are a number of outstanding matters requiring attention but action plans are underway. This includes matters of fire safety such as suitable door locks; magnetic door holders to hold fire doors open and in addition the external fire escape route to the side of the home needs to be kept clear of furniture and overgrown vegetation. Window security also needs to be reviewed. EVIDENCE: This home has consistently demonstrated a professional and well organised approach to the provision of care and is clearly run with the best interests of the service users uppermost in everyone’s mind. Fire safety matters as listed above need to be addressed without undue delay and the manager confirmed during the inspection that the home has in place an action pan to identify suitable locks and door holders and for the gardener to clear the side access route. The home also needs to review where window restrictors are required. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 14 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 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 3 x x x x x x 1 Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 15 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 38 Regulation 24(4) Requirement Fire safety: Fire escape routes, internally and externally to be kept clear; magentic door holders to be fitted where doors need to help open; suitable lcok to be fitted to bedroom on fire escape route. Timescale for action 30/8/05 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 38 Good Practice Recommendations Security: it is recommended that window security throughout the home is reviewed to ensure the safety of service users by avoiding unwelcome unauthorised in to the building. Acacia Lodge Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 16 Commission for Social Care Inspection CSCI 8th Floor Grosvenor House 125 High Street, Croydon CR0 9XP 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 Nursing Home G53-G53 S19018 acacia V236375 130705 stage 4.doc Version 1.40 Page 17 - 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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