CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE
Acacia Lodge Nursing Home 15 Wellingborough Road Irthlingborough Northants NN9 5RE Lead Inspector
Stephanie Vaughan Unannounced 13 June 2005 10:00 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 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 DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Acacia Lodge Nursing Home Address 15 Wellingborough Road Irthlingborough Northants NN9 5RE 01933 651660 01933 652948 dianeprycedyer@bupa.com Bupa Care Homes(AKW) Limited (Frederick Stanley) Vacant Care Home 40 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) Category(ies) of TI(E) Terminally ill - 5 registration, with number OP Old age - 5 of places PD(E) Physical dis - over 65 - 18 PD Physical disability - 18 DE(E) Dementia - over 65 - 21 Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 18.11.04 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. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection was conducted over a period of four and a half hours during which the inspector made observations and spoke to two residents. Limited feedback was obtained from residents due to the level of their disability. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of three residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. Three members of staff were spoken to and a selection of staff files were viewed. Prior to the inspection a period of 90 minutes was spent in preparation, which included a review of previous inspection and monitoring visit reports, associated requirements, correspondence, notifications, service history and comment cards received from residents and their representatives. Eleven comment cards were received and included three very positive comments about the care provided by the home. A further three indicated that the home might not have sufficient staff and one referred to the previous absence of a manager. Two comments were also made about the maintenance of facilities and one related to the laundry systems and these were addressed during the inspection. What the service does well:
All residents were seen to have appropriate risk assessments for pressure, associated documentation, access to appropriate specialists and pressure relieving equipment. Acacia Lodge has a dedicated activities coordinator who arranges a range individual and communal activities for the residents and notices are displayed within the home to inform residents. Residents are also able to choose whether they wish to participate in an activity.
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 6 The home has access to a corporate complaints policy and evidence was seen within the complaints file that complaints are taken seriously and fully investigated with the complainant being informed of the outcome. Staff demonstrated a good understanding of the residents needs and were seen to relate well to residents. What has improved since the last inspection?
The homes Statement of Purpose has been reviewed since the recent monitoring visit (April 2005). The pre admission assessment document has been reviewed following a previous requirement and now captures a greater level of information to enable the home to assess whether it is able to meet the needs of prospective residents. Individual plans of care have improved and now provide good information regarding the residents’ needs for health, personal and social care needs. Individual Plans of Care evidenced that residents’ psychological needs are monitored and provided staff with instruction regarding appropriate interventions and behaviour management techniques. Aspects of privacy and dignity have improved at Acacia Lodge since the last inspection and the residents within all areas of the home appeared to be calm, the noise levels from televisions and musical activity are now controlled to ensure residents comfort. Meals were served in a congenial setting and residents requiring assistance were supported appropriately with encouragement, sensitivity and patience. Residents on each floor were observed to be moving freely within their environment. Only one resident was reported to need limited access to his private accommodation for his own safety and this was supported by an appropriate risk assessment within the care plan. The home has made several improvements to the environment since the last inspection and monitoring visit and further refurbishment is planned for the near future. Furnishings have now been replaced and are generally well maintained. Appropriate graphic signage has now been installed to enable residents with dementia to access lavatories, bathrooms and their own personal
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 7 accommodation. The home is now generally well-maintained, clean and hygienic with adequate provision of gloves and incontinence wipes. Staffing levels have improved with five new staff have been appointed with staffing levels now increased to seven in the morning, six in the afternoon and four at night. Staffing levels include a registered nurse on duty for all shifts and further recruitment is ongoing. The management are mindful of the Department of Health Target regarding 50 of staff to have undertaken National Vocational Qualification Training at level 2 by 2005 and three staff are currently undertaking the training. It is anticipated that a further five new staff will commence training in September, which will enable the home to meet the target. Staff have received training in Dementia Care and there was evidence that further mandatory training in Confrontational Behaviour is scheduled for the near future. The Registered Provider has recently appointed an experienced manager to run the home. It is recommended that the manager seek registration with the Commission for Social Care Inspection at the earliest opportunity What they could do better:
The Statement of Purpose should be further reviewed and improvements should be made to the level of information provided. This should include more information on staffing, e.g. detail about the provision, number and qualifications of the nursing staff provided, the fire precautions and information about how to complain. The pre admission assessment document should be further reviewed to include for example a history of falls, risks, weight and personal preferences. The individual plans of care now need to be developed to include more detailed and accurate instruction to staff about how a specific need should be met and to include the resident’s preferences. Risk assessments should be reviewed to ensure that detailed instructions provided to staff about how a risk is to be reduced or managed. Action should be taken to ensure that all identified needs are addressed and residents have access to appropriate services e.g. Advocacy. The home should seek referral to a dietician for residents identified as having a high nutritional risk and guidance should be sought regarding the use of appropriate feeding aids. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 8 The medication policy should be reviewed to contain instruction to staff regarding the action to be taken in the event of missing medication or a medication administration error. An investigation into the missing medication must be undertaken and a report submitted to the Commission for Social Care Inspection, regarding this incident. Laundry systems should be reviewed to ensure that residents’ laundry is returned to the appropriate resident. Systems to ensure the Protection Of Vulnerable Adults must be improved, including further review of the policy documentation, staff training and staff access to the Local Authority Guidelines Recruitment practices must be improved to ensure that residents are protected. Staff files evidenced shortfalls in recruitment practices with the recent appointment of a carer based on only one reference and prior to receipt of either a satisfactory povafirst check or formal Criminal Records Bureau Clearance. Staff supervision and mandatory training must be improved. Safety issues such as the maintenance of wheelchairs and the security of chemical items stored in residents’ rooms must be addressed 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 DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 9 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 Standards 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 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 10 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. 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. Prospective service users have an opportunity to “test drive” the home. 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 standard(s) 1 ,3 & 4 The needs of residents admitted to the home are generally met. EVIDENCE: The homes Statement of Purpose has been reviewed since the recent monitoring visit (April 2005) and now covers the criteria listed in schedule 1 of the National Minimal Standards. However the purpose of this document is to provide information to a range of different parties and the document would benefit from a more user-friendly style. For example many of the statements include a reference to a specific BUPA policy, which is intrusive to the text and to which the reader might not have access. The document should contain information that informs the reader and improvements should be made to the information on staffing, to include detail
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 11 about the provision, number and qualifications of the nursing staff provided. Improvements should also be made to the level of information that is provided in relation to the fire precautions and complaints. Residents are admitted to Acacia Lodge following pre admission assessment the assessment document has been reviewed following a previous requirement and now captures a greater level of information to enable the home to assess whether it is able to meet the needs of the resident. However the document the document should be further reviewed to ensure that all of the criteria listed Standard 3 are included for example a history of falls, risks, weight and personal preferences. Residents spoken to confirmed that the home was able to meet their needs. Through observations made and the documentation viewed including individual plans of care and staff training records viewed generally supported this. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 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 standard(s) 7, 8, 9, & 10 Further improvements must be made to the individual care plans, health care, medication systems and privacy and dignity to ensure that residents’ needs and expectations are met. EVIDENCE: Each resident was seen to have an individual plan of care based on the pre admission assessment which in the main included the criteria listed in schedule 3 of the National Minimum standards
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 13 Care plans have improved and now provide good information regarding the residents’ needs for health, personal and social care needs. However the individual plans of care now need to be developed to include more detailed instruction to staff about how a specific need should be met and to include the resident’s preferences. For example one very dependent residents care plan for personal hygiene indicated that hair nails and teeth should be attended to, although there was insufficient detail regarding how this was to be done, or of the residents preferences. In addition the same care plan indicated that the resident was to have a weekly shower or a bath, although another record indicated that as the residents dependency had increased that a blanket bath was required. All of the plans of care viewed contained risk assessments for falls however there was inconsistent detailed information regarding the action to be taken to reduce or manage the risk. Individual care plans evidenced regular internal review and reviews with the placing authority, which include the resident’s representative. However one dependant resident was noted to have no representative and a recommendation had been made by the Care Manager that an advocate should be appointed to represent the residents best interests, however there was no evidence to demonstrate that this had been done. All residents were seen to have appropriate risk assessments for pressure, associated documentation, access to appropriate specialists and pressure relieving equipment. Nutritional assessments were seen to be in place for all residents and to evidence regular review. However some residents were seen to have a high level of risk and swallowing difficulties. There was evidence that the home had obtained thickeners for liquid intake and that food was blended appropriately. However, one resident with particular swallowing difficulties was seen to have fluids provided through the use of an infant feeding bottle. This intervention was inconstant with the instruction provided in the care plan, that stated that a feeding beaker should be used at all times. The use of the feeding bottle was not supported by a risk assessment nor was there any evidence seen that guidance from a dietician had been sought regarding the needs of vulnerable residents. Individual plans of care evidenced that residents have access to the Continence Advisory Service and appropriate supplies. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 14 Individual Plans of Care evidenced that residents’ psychological needs were monitored and provided staff regarding appropriate interventions and behaviour management techniques. In general, individual plans of care evidenced access to appropriate medical and specialist services, such as general practitioners, hospitals, dentists, opticians, and chiropodists. The medication systems were viewed and seen to be generally in good order. Medications are managed by the use of a pre packaged dispensing system on a monthly basis and the medication administration records were seen to be in good order. However some medications are supplied in their original packaging and a shortfall of six tablets had been identified. Although enquiries had been made no outcome had been achieved. The medication policy was viewed and seen to contain no instruction to staff regarding the action to be taken in the event of missing medication or a medication administration error. In addition the Commission for Social Care Inspection have not received a regulation 37 notification regarding this incident. Privacy and dignity has improved at Acacia Lodge since the last inspection, staff were seen to relate well to residents at all times and speak to them in their preferred form of address as specified with in the care plan. Staff were seen to knock on the doors of residents individual accommodation and wait permission prior to entering. Staff ensure that personal care and consultations are delivered in private and residents are able to receive their chosen visitors in privacy if they wished. Residents appeared well presented and to be wearing their own clothing. However one of the comment cards received indicated that there had been at least one occasion where a resident had been dressed in someone else’s clothing. The resident concerned to gave permission to the inspector to check the contents of the wardrobe. Clothing was labelled with the individual’s room number, to be of a good quantity and well maintained. However the wardrobe contained at least one set of clothes that belonged to a resident occupying a room nearby. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 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 standard(s) 12,13,14& 15 Daily life and social activity are generally managed well at Acacia Lodge EVIDENCE: Acacia Lodge has a dedicated activities coordinator who arranges a range of activities for the residents and notices are displayed within the home to inform residents. Where residents are unable to participate in a planned activity alternative individual arrangements are made. Residents are also able to choose whether they wish to participate in an activity. The residents within all areas of the home appeared to be calm, the noise levels from televisions and musical activity are now controlled to ensure residents comfort. Individual plans of care evidenced some personal preferences regarding food types, routines and activities however these were not always consistently recorded and this is an area for further development.
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 16 Residents are able to receive their chosen visitors in privacy if they choose and visitors were seen to come and go throughout the inspection. Residents are supported to be as independent as their condition allows and rooms evidenced personalisation, care plans evidence some involvement in the care planning process. The lunchtime service was viewed and seen to comprise of braised steak, mashed potatoes, vegetables and gravy with an alternative of sausage and chips. A choice of deserts was also available. The food provided appeared to offer a balanced diet. Meals appeared to be well presented, of adequate proportion and to be well received by residents. Residents spoken to were able to confirm satisfaction with the food provided. Meals were served in a congenial setting and residents requiring assistance were supported appropriately with encouragement, sensitivity and patience. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 17 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’ legal rights are protected. Service users are protected from abuse. Including neglect and selfharm. 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 standard(s) 16 & 18 Residents feel their concerns are listened to and addressed, however the systems to protect residents from abuse are inadequate. EVIDENCE: The home has access to a corporate complaints policy and evidence was seen within the complaints file that they were taken seriously a fully investigated with the complainant being informed of the outcome. The home has one complaint outstanding, which has been referred for investigation to a staffing agency for investigation and is currently awaiting their response. Residents confirmed that they felt safe at Acacia Lodge and their satisfaction with the staff. The home have recently had two incidents, which have implications for the Protection Of Vulnerable Adults, which have been managed appropriately by senior staff. Staff spoken to were aware of their responsibilities for the Protection Of Vulnerable Adults and of the internal arrangements for identifying and
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 18 reporting incidents. However staff were not consistently aware of the Local Authority Guidelines and the external action that would need to be taken. Staff spoken to and files viewed evidenced that some staff had received training in the Protection Of Vulnerable Adults, however not all of the staff spoken to had received this training and this was also evident from the staff files viewed. The Protection Of Vulnerable Adults policy was viewed and seen to comprise a policy statement with external contact details, the policy was not dated or signed although the senior member of staff believes this to be the most recent guidance and to have been developed as a result of the requirement made during the last inspection. However the Protection Of Vulnerable Adults policy displayed on the notice board in the downstairs Nursing station was seen to be a much more comprehensive document although to be out of date in terms of reference to the Local Authority Guidelines, and reporting arrangements. A previous recommendation was made regarding the practice of restricting access to the residents’ rooms during the day by locking bedroom doors. However residents on each floor were observed to be moving freely within the environment. Only one resident was reported to need limited access to his private accommodation for his own safety and this was supported by an appropriate risk assessment within the care plan. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 19 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 have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. 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 standard(s) 19, 22 & 26 The environment has been improved and is now able to meet the needs of residents. EVIDENCE: The home has made several improvements to the environment since the last inspection and monitoring visit and further refurbishment is planned for the near future. Existing improvements include refurbishment of the communal areas including the first floor lounge. Furnishings have now been replaced and are generally well maintained. A further small sitting room on the first floor has been made into a quiet area and is appropriately furnished. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 20 One radiator guard has been damaged and this was due to be addressed by the maintenance person. Appropriate graphic signage has now been installed to enable residents with dementia to access lavatories, bathrooms and their own personal accommodation. The home is now generally well maintained, clean and hygienic with adequate provision of gloves and incontinence wipes. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 21 Staffing
The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Staffing levels and staff training continues to improve to ensure that the residents’ needs are met. Recruitment practices are inconsistent and may place residents at risk of abuse. EVIDENCE: Three comment cards suggested that there might not always be sufficient staff on duty and the previous monitoring inspection report recommended that staffing levels be calculated according to the guidance issued by the Department of Health Residential Forum for care home staffing. The deputy manager confirmed that this had been done and staffing levels increased accordingly. Five new staff have been appointed with staffing levels now increased to seven in the morning, six in the afternoon and four at night. Staffing levels include a registered nurse on duty for all shifts. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 22 Further recruitment is ongoing to enable a further full time carer to be appointed to the day shifts and a further five night shifts per week. The care staff are supported by the provision of domestic, laundry, maintenance and catering staff. Staff files evidenced shortfalls in recruitment practices with the recent appointment of a carer based on only one reference and prior to receipt of either a satisfactory povafirst check or formal Criminal Records Bureau Clearance. The management are mindful of the Department of Health Target regarding 50 of staff to have undertaken National Vocational Qualification Training at level 2 by 2005 and three staff are currently undertaking the training. It is anticipated that a further five new staff will commence training in September, which will enable the home to meet the target. Staff have received training in dementia Care and there was evidence that further mandatory training in Confrontational Behaviour is scheduled for the near future. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 (Older People) and Standards 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 and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 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 standard(s) 31, 36 & 38 The appointment of a permanent manager to the home is a significant improvement, however further improvements are required to ensure that outstanding issues are addressed. EVIDENCE: The Registered Provider has recently appointed an experienced manager to run the home and staff spoken to confirmed that the home was benefiting from the stability and leadership that is now provided. The acting manager has not to date sought registration with the Commission for Social Care Inspection.
Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 24 Staff files evidenced that staff supervision is not being undertaken; this was confirmed by members of staff spoken to and the deputy manager. This should be re-established to address any dissatisfaction and to provide support and direction to staff regarding the expectations and responsibilities required. Staff Files and staff spoken to confirmed that staff have access to some mandatory training including Movement and Handling, Food Hygiene and Fire although this was not consistent for all staff. There was little evidence to indicate that staff receive training in infection control, or first aid training and there must be sufficient numbers of staff trained in first aid to ensure that a designated first aider on duty for each shift. A previous immediate requirement was made on the 4th April 2005 regarding the safety of wheelchairs. This continues to cause concern, as on this occasion three wheel chairs were identified as being unsafe, being without footplates. The member of staff present informed the inspector that these wheelchairs were not in use being beyond repair. A further immediate requirement was made for the wheelchairs identified, to be reviewed and made safe. If found to be beyond repair then they must be disposed of to protect the health and safety of residents. A limited tour of the premises was conducted and two items were removed from the residents’ rooms, the first being Steradent tablets which if ingested present a serious risk to the health and safety of residents. In addition a tube of Fucidin cream was removed from a room on the first floor, this was neither named, dated or securely stored. This floor caters for vulnerable residents with dementia who are at greater risk from inappropriate ingestion. Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 25 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 x 3 2 4 2 5 x 6 N/A
HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26
STAFFING Score 3 x x x x x x 3
Score Standard No 7 8 9 10 11 Score 2 2 1 2 x Standard No 27 28 29 30 3 3 1 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION Standard No 16 17 18 Score x x 1 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 x 34 x 35 x 36 1 37 x 38 1 Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 26 YES 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 7 Regulation 15 (1) & (2) Requirement A written care plan must be produced, that accurately identifies all of the residents assessed needs and gives clear instruction to staff to enable them to meet the needs and preferences of the residents ( previous timescales 15/01/04 & 31/07/04). The timescale of 30/06/05 is extended to 30/07/05 Residents assessed as medium and high risk for falls must have detailed instuction to staff as to how the risk is to be managed or reduced. Residents must have access to appropriate specialist services and advocates An investigation must be conducted into the missing medication and a report and a notifictation ( reg 37) must be submitted to the Commission The Protection of Vulnerable Adults must be reviewed to provide comprehensive and accurate information to staff ( Previous requirements 27/02/04, 31/07/04 & 30/06/05 Timescale for action 30/07/05 2. 7 13 (4) 30/07/05 3. 4. 8 9 12 (1) (a) 13 (1) (b) 13 (2) 30/07/05 30/07/05 5. 18 13 (6) 30/07/05 Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 27 6. 18 18 ( C ) 7. 29 Schedule 2 Staff training must be reviewed to ensure that all staff have acces to training in the Protection of Vulnerable Adults New staff must only commence employment following receipt of two satisfacory references and receipt of appropriate Criminal Records Bureau Clearance 30/08/05 30/07/05 8. 9. 8 Staff training must be reviewed to ensure that staff receive mandatory training at appropriate frequencies. 23 (2) (c ) Wheelchairs identified as being unsafe must be reviewed and made safe or disposed of.Immediate Requirement. 13 (4) (c Steradent tablets must be & b) stored in a locked container and residents’ access must be supported by an individual risk assessment. Immediate Requirement. 13 Medication required for residents must be appropriately labelled. Safe storage must be maintained when items are retained for use in resident’s individual accommodation within a locked container. Immediate Requirement. 18 (1) 30/07/05 10. 38 14/06/05. 11. 38 14/06/05 12. 38 14/06/05 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 1 Good Practice Recommendations The Statement of Purpose should be reviewed to ensure a more reader friendly format and to include greater detail regarding the qualifications of staff, fire precautions and how to make a complaint. The pre admision assessment documentation should be
DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 28 2. 3 Acacia Lodge Nursing Home 3. 4. 5. 10 15 36 reviewed to ensure that all of the criteria listed in standard 3.3 are included. Laundry systems should be reviewed to ensure that residents clothing is returned to the correct owner Individual plans of care should be reviewed to ensure that residents personal preferences are consitantly recorded. Staff should receive formal supervision 6 times yearly Acacia Lodge Nursing Home DC51 C08 S29163 Acacia Lodge V232165 130605 stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection First 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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