Inspection on 18/04/07 for Acacia Lodge Nursing Home

This inspection was carried out on 18th April 2007.

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

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

Other inspections for this house

Acacia Lodge Nursing Home 13/07/05

Acacia Lodge Nursing Home 04/04/05

Acacia Lodge Nursing Home 21/09/04

Acacia Lodge Nursing Home 29/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acacia Lodge Nursing Home 1 Stanhope Road Croydon Surrey CR0 5NS Lead Inspector Michael Williams Key Unannounced Inspection 18th April 2007 9:45am X10015.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 DS0000019018.V332734.R01.S.doc Version 5.2 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. 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 DS0000019018.V332734.R01.S.doc Version 5.2 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 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) 020 8688 8000 020 8667 1060 acacia@irh-homes.com London Residential Healthcare Limited Mrs Ellen Teresa Ryan Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 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 ten 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. Fees as at April 2007 were £525 to £700. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. To monitor all aspects of care the inspector ‘tracked’ the care provided to a sample number of residents and cross checked the information by examining the documentation supporting care, observing the meals provided, checking the arrangements for medication, handling money, records of complaints, accidents and nutrition. Staff providing care were interviewed, and where possible the inspector met with relatives as well as interviewing or observing the residents themselves. Questionnaires were also distributed and we received seven written responses by the time of our visit on 18th April 2007. What the service does well: What has improved since the last inspection? What they could do better: The home appreciate that some bedrooms are smaller than modern standards and few have ensuite facilities as some residents might wish for. Two matters of serious concern were identified during the inspection but were corrected on the day of inspection. The first was a failure to record Control Drugs on site but no longer required and secondly a fire exit through a bedroom was obstructed by an unsuitable door lock (which was removed during the inspection visit). For these two matters recommendations are made to ensure systems are in place to ensure similar problems do not arise in the future. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 3: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users have a comprehensive assessment carried out by staff qualified to do so 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: A sample of residents’ case files were used to cross-check or ‘track’ information. Carers and nursing staff contributed in the assessment of this standard as did the manager. The residents and several visitors 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 resident then has an individual and comprehensive care plan - drawn up in collaboration with the resident if this is possible or their relatives if it is not. A large proportion of residents are self-funding and do not require the assistance of the local authority service services; in these cases the home can undertake its own assessments to ensure the home can meet their needs. It is evident that significant time and effort is spent making admissions to the home Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 9 personal and well managed. Prospective residents and their families are treated with dignity, respect and with an understanding for the life changing decisions they need to make. Sadly some residents would wish to remain in their own homes but recognise the need for the 24-hour care provided in care homes and to that extent very much appreciate the service provided in Acacia. Family and friends are consistently involved in the admission and subsequent care planning of each resident. Areas of strength are information and support provided at the point of admission and as there are no matters requiring improvement this section, about choice, is assessed as good. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 8 9 10 and 11: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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: Residents and their visitors explained how the home involves them in all aspects of their care. Each resident has a well thought out care plan using a standardised format. The home has effective systems in place to ensure care plans are reviewed and updated monthly and arranges additional more formalised reviews when changes take place. Innovative methods such as the use of translations, hearing and visual support devices can be used to enable residents to participate and communicate their views to the development of the care plan and the review process. Feedback and involvement is a continuous ongoing process; staff (including ancillary staff such as the cooks) spend time with individual residents to ensure they understand decisions and actions. Robust quality monitoring systems are evident such as the positive use of owners’ visits and questionnaires. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 11 The care plans are simple in design making them easy to use by all levels of staff and it is clear they are being used as daily a working tool. Much of the information is codified for quick and easy use but the care plans can be readily used in an emergency by people who are not familiar with its content. Each care plan includes comprehensive risk assessments of key areas such as nutrition, skin care, mobility and so forth. The staff keep up to date with training, professional research and literature, in both the social care and clinical fields; for example on the day of inspection training was taking place in the home for staff to update their “appointed firstaider” training. Nurses including “Adaptation Nurses” maintain their clinical skills and their registration with NMC [Nurse and Midwifery Council]. Staff actively promote the residents’ right of access to the health and remedial services that they need, both within the home and in the community. Regular appointments are seen as important and there are systems in place to make sure residents are reminded and appointments are not missed. Records show that the home arranges for health professionals to visit frail residents in the home and provides facilities to carry out treatment. Staff keep a regular check on health aids, making sure they are working effectively and that each resident has the necessary aids to improve their quality of life Residents have choice over their personal care and are encouraged to be independent and responsible for their own personal hygiene where possible. The home operates to well developed and efficient medication policies and procedures. Staff all have access to the written information and understand their role and responsibilities. However, whilst the medication records are seen as vital both for ensuring the good health of residents and the accurate recording of medicines on the premises one serious lapse in recording was identified. Not all Control Drugs had been recorded in line with good practice and the home’s own procedures. The lapse occurred appears to have occurred because the last stock of medication arrived after the death of the resident for whom they were prescribed; nevertheless these drugs should have been recorded as received, held and then disposed of. As the omission was corrected at the time of the inspection a recommendation rather than a requirement is made to ensure good practice in this area is maintained at all times. The need to respect residents’ privacy and dignity when delivering health and personal care is a key principle of the homes aims and objectives and is stated in their Guide. Staff are aware that this also applies to all areas of the resident’s life. Residents are consulted and can help decide with the senior nurses which staff members they want to help them with their personal care. The registered person routinely observes staff attitude and approach to privacy and respect and constantly seeks and values residents’ views and experiences. This is not a very large nursing home and so the Matron can easily get to know all residents and their regular visitors and those who spoke to the inspector Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 12 described her as very approachable. The wishes of individual residents about dying and terminal care, and the arrangements they want after death can be openly and sensitively discussed with both the residents and their family during the development of the care plan. But it was clear from the care plans that few residents actually want to discuss their end of life wishes; nevertheless the home has prepared staff for this sensitive work including talks by undertakers and Coroners as well as priests and other support staff that might be involved in end of life care. The home has a detailed policy, procedure and practice guidance to help staff when handling terminal care and death. All staff receive in house training and practical advice in caring for these residents, and have continuous support and opportunities to discuss any areas of anxiety and concern. Facilities are provided to allow relatives and friends to stay with the resident and to assist with their care if the residents want this. Despite Acacia being a nursing home where the turnover of residents might be expected to be high there are many residents who remain relatively healthy into their 90s and there are a couple of centenarians here – this pays tribute to the quality of care provided. Areas of considerable strength are detailed and comprehensive care planning and consultation processes and the high standard of health and social care and as no matters requiring improvement arise this section, about health and personal care, is assessed as excellent. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 13 14 15: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a very congenial setting which offers a 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: Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. The home has sought the views of residents and considered their varied interests and abilities when planning the routines of daily living and arranging activities. Routines are very flexible and residents can make choices in major areas of their life. The routines, activities and plans are resident focussed, regularly reviewed, and can be quickly changed to meet individual residents needs. The activity coordinator explained how this happens and includes daily contact with the residents to offer them choices and how the day will be spent. On the day of this inspection several residents wanted to enjoy the Spring sunshine in the garden patio area and so watch the bluebells and wisteria now in bloom. Others enjoyed a quiz in the main lounge and tell us the new chairs are very comfortable for them. Both the television and daily Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 14 newspapers were being used positively and constructively to keep residents it touch with news and world affairs. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors were on site and told us how they are welcome at any time and facilities are available for them to have a drink or a meal with the resident. Residents can choose to entertain visitors in their own rooms or perhaps a lounge or the delightful garden areas. This home does not have small kitchenettes not domestic scale laundry facilities but in so far as it is possible residents are encouraged to be independent, for example to be responsible for their own money and medication. Staff give help when it is needed and have contacted advocacy groups and encouraged their involvement with individuals in the home. The home’s policies, procedure, guidance and quality assurance systems ensure that service users are protected from financial abuse. The service is very clear about the rights of residents to be able to read their records and staff spend time with them making sure that they are fully aware of their care plans which are held by the home. Food is considered to be highly important and meal times considered a social occasion. The cooks in Acacia are qualified and experienced in cooking for older people, and are seen as important members of the staff team and their records show they are well acquainted with the need to keep records dietary and cultural needs of each service user. The cooks, one of whom is a new member of the catering team, are committed to involving service users in menu planning and making sure that they are able to enjoy the food they prefer and like. The menu is varied, balanced and nutritious. It has a number of choices including a healthy option, and includes a variety of dishes that encourage service users to try new and sometimes unfamiliar food. On the day of inspection there were two main choices including liver or ravioli plus omelettes, ham salad, fish and chips and sandwiches - plus diets. Food is served to meet the need of all service users including those who have swallowing or chewing difficulty. Staff giving assistance to those residents who need help to eat, were discrete and sensitive. Mealtimes are relaxed affairs, staff were patient and helpful, and gave service users the time they needed to finish their meal comfortably, encouraging them to serve themselves. We spoke to residents as group in the dining room and all the residents appreciate the good quality food they are served and being able to have a drink when they wish and the availability of snacks. They also enjoy being able to eat in their own room when they wish. Amongst the choices that service users can make known, or their family can assist them in making known, are the residents’ cultural and diversity needs. At present all the residents in Acacia are of English background and some of the staff share a common background with service users, though not all do and there are no male carers for those residents who may wish to choose the gender of the person to provide personal care. The home seeks to ensure residents can follow their religious and cultural beliefs whether that is in the form of worship, leisure pursuits or special diets. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 15 Areas of strength are the range activities, the entertainment and sociable atmosphere prevailing in the home; the feedback from residents and visitors about the quality of life in the home and the flexibility of staff to accommodate individual choice and as no matters requiring improvement arise this section, about daily life, is assessed as excellent. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 18: Quality in this outcome area Excellent. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: Acacia has a complaints procedure that is up to date, clearly written, and is easy to understand. It can be made available in a number of formats (including other languages, large print, audio-tape) to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is widely distributed, and has a high profile within the service; for example, it is on display in the entrance hall and in both the Statement of Purpose and residents’ Guide. Residents and visitors have a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made; several visitors explained that when they have had minor concerns they have been dealt with in a timely and helpful way. The policies and procedures regarding protection of residents are in place and regularly reviewed and updated. The service is clear when incidents need to be referred to the local Social service Department and/or the police as well as other involved parties. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 17 The Manager confirms that there have been no such incidents requiring referral under these procedures. Training of staff in the area of protection is regularly arranged by the home. Residents and others associated with the Acacia say that they are very satisfied with the service provision, feel very safe and well supported by an organisation that has their protection and safety as a priority. Several residents pointed out that it was joint family decision that they enter the home to ensure their own safety and expect to be kept safe from accident injury or abuse. The promotion of the individual’s rights is central to the aims and objectives of the service and as a central plank of the homes’ statement of purpose, the home’s documentation reflect the rights of the individual. Advocacy can be arranged if needed to support a resident. Staff ensure that residents can access places of worship or community facilities of their choice. Areas of strength are clear information provided about making concerns known which are in formats residents and their relatives can understand. As well as a positive attitude of the home and owners to deal with those concerns. No matters requiring improvement arise this section, about complaints and protection. This outcome group has been assessed as excellent. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19 26: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users live in a very safe, well-maintained and comfortable environment. It is subject to ongoing refurbishment and renewal. It was clean and tidy at the time of inspection. The garden are spacious and so provide choice about where to sit. EVIDENCE: Acacia is unusual as nursing home in that it was a former town-house with spacious, if rather sloping, grounds and of particular note is the entrance hall. This provides a very homely and pleasant welcome for visitors and gives an excellent first impression to prospective residents. The home has a well-maintained environment, which provides aids and equipment to meet the care needs of the residents. It is a very pleasant, safe place to live with a wide variety of bedroom styles – some of which meet national minimum standards although not all do as many are without ensuite facilities and some bedrooms are not large. Where rooms are shared it is only by agreement, and screens provided for privacy. Residents are always given the choice to move into a single room Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 19 when one becomes vacant. Residents showed us that they have the choice to bring small personal items of furniture into the home. All the homes fixtures and fittings meet the needs of the residents and can be changed if their needs change. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. Some residents say they would like to keep their bedroom doors open so they will need to have suitable safety device fitted if they are to do so. A recommendation is made to fit such devices where needed. It is noted that many doors already have portable magnetic holders. There is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. Residents say that there is plenty of hot water at all times of the day and the temperature of bedrooms can be changed, on request. The place is well ventilated, the home is well lit, clean and tidy and smells fresh. The management has a good infection control policy. They seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. In the past inspection report the home was required to change the locking mechanism to a bedroom door that leads to a fire escape. The home has fitted a single-action lock to the outer door but has yet to fit a suitable one to the inner door (leading from the upstairs landing into the bedroom; a recommendation is made to find a suitable lock for this door. Areas of strength are well maintained premises, the homely atmosphere and the range of aids and adaptations in use; the grounds are also an asset. No maters requiring improvement arise so this section, about environment, is assessed as good. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 20 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27 to 30: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. 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: Residents tell us that they have confidence in the staff that care for them. Rotas are clear and simple and show how nursing and care staff are to be deployed and that adequate numbers of ancillary staff are also working in the home – indeed the ancillary staff, cooks, cleaners, maintenance and laundress were complimented for the important part they play in the running of the home. The home clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. Residents report that staff working with them are very skilled in their role, and are consistently able to meet their needs. There is little use of any agency or temporary staff. The service ensures that all staff within its organisation receives relevant training, including nursing and care qualifications, that is targeted and focussed on improving outcomes for residents. The service uses external providers to deliver this training if they have not got the appropriate skills within the organisation. This training can be small scale and individualised if necessary in order to promote the delivery of person centred services. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 21 recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of residents. A sample of staff records were examined and staff interviewed to confirm good practice in recruitment processes. Areas of strength are stability and loyalty of the staff team that is well trained and skilled in their various roles and as no matters requiring improvement arise this section, about staffing, is assessed as good. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 22 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31 33 35 37 38: Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 service for residents, with regards to both environment and personal care. Residents’ needs are a key consideration to the running of the home and their care and well being is seen as paramount. EVIDENCE: The manager Mrs Ryan has the required qualifications as a nurse and manager and has considerable experience as a home manager so she is clearly very competent in running Acacia Lodge as a nursing home. She works to continuously improve services and provide an increased quality of life for residents, a point repeatedly confirmed by the residents. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is resident-focused and leads and supports a strong staff team who Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 23 have been recruited and trained to a high standard. The home has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. The manager is regarded highly by other professionals. Staff are positive in their approach to translate policy into practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that they receive feedback on their work. The home works to a clear health and safety policy, all staff are given a copies of important policies in particular those relating to staff and resident safety. There are regular random checks to ensure staff are working to these policies. The home has a good record of meeting relevant health and safety requirements and legislation, fire safety, hygiene and maintenance checks are all confirmed by regular certification by the relevant authority. Records are of a good standard and are routinely completed and samples were checked during the inspection to confirm this including, case files, staff files, safety records, food records complaints and accident records. Where issues have been identified, for example, in care plans, these have been acted upon successfully to ensure residents care is not compromised. Residents are aware of safety arrangements and have confidence in the safe working practices of staff. The registered person has the skills and ability to deliver good business planning, effective financial controls and provides a quality assurance and monitoring processes. We are advised that home’s financial and business plan shows continuing growth supported by strong financial arrangements. The home has access to professional business and financial advice and has all the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. Residents are helped to take responsibility for managing their own money. They are provided with facilities to keep their valuables and money safe. Where the home is responsible for resident’s money it works to a very rigorous system, it maintains very clear records that are routinely kept up to date and can be used to track individual residents finances. Two matters of safety arose; one about medication records and another about a suitable door lock on fire escape route. Neither posed an immediate risk and as both issues were resolved during the inspection but recommendations are made about both points. Areas of strength include the overall management and daily running of the home backed by owners committed to quality services and as no matters requiring improvement arise this section, about management and administration, is assessed as excellent. Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 24 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X 4 3 Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 Refer to Standard OP9 Good Practice Recommendations Medicine records: it is recommended that all drugs including controlled rugs be recorded promptly when they arrive on the premises so as to ensure good stock recording and management of medicines. Errors found on the day were corrected immediately so no risk was posed to residents. Fire safety and choice: it is recommended that magnetic door holders be fitted where residents would wish their bedroom door kept open. Fire safety and privacy: it is recommended that a suitable lock be fitted to the bedroom door that leads to a fire escape route. The (unsuitable) lock has been removed to ensure evacuation is not impeded. 2 3 OP19 OP38 Acacia Lodge Nursing Home DS0000019018.V332734.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000019018.V332734.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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