Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 20/08/07 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 20th August 2007.

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

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

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

Good information informs new residents about the home. The home has a warm and friendly atmosphere. The service is able to support the equality and diversity needs of residents. Residents were seen to be supported with respect and that the service is person centred. There is a very positive commitment to training with many staff undertaking extensive training in meeting the needs of people with a dementia. All carers undertake mandatory training. There is a strong commitment by the management team to maintain and improve standards at the home.

What has improved since the last inspection?

The pre-admission assessment tool has been developed to ensure that sufficient information is sought prior to admission.

What the care home could do better:

Care files need to contain a contract signed by the resident and or their representativeThe manager needs to ensure that all staff members receive supervision at least six times per year and is well documented.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Acacia Lodge Nursing Home 15 Wellingborough Road Irthlingborough Wellingborough Northants NN9 5RE Lead Inspector Kathy Jones Key Unannounced Inspection 11:00 20th August 2007 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acacia Lodge Nursing Home DS0000029163.V346709.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Nursing Home Address 15 Wellingborough Road Irthlingborough Wellingborough Northants NN9 5RE 01933 651660 01933 652948 thedurrantm@bupa.com www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Diane Pryce-Dyer Care Home 40 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (5), of places Physical disability (18), Physical disability over 65 years of age (18), Terminally ill over 65 years of age (5) Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2006 Brief Description of the Service: Acacia Lodge is a home situated on a main route within the small town of Irthlingborough in Northamptonshire. The home is within walking distance of Irthlingborough Town Centre where community resources include churches, shops, pubs and restaurants. The home is owned by BUPA Care Homes Limited and is registered to provide both Nursing and personal care for service users with a variety of needs, the majority of which are over 65 years of age. Accommodation to the service users is provided across two floors, there are 30 single rooms and 5 double rooms with the majority providing en suite facilities. The home has four lounge areas, one of which is a designated smoking area and a dining room on both floors. Access to the first floor of the home is by passenger lift. Fee Levels at the home range from £450 - 600 Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 3 service users and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The registered manager completed an annual quality assurance assessment (AQAA) prior to the inspection and contained evidence that supported the outcomes within this report. The inspection took place during the late morning and afternoon, over a period of 6 hours and was carried out on an unannounced basis. What the service does well: What has improved since the last inspection? What they could do better: Care files need to contain a contract signed by the resident and or their representative. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 6 The manager needs to ensure that all staff members receive supervision at least six times per year and is well documented. 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 DS0000029163.V346709.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Standard 6 does not apply (older people) and 2 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s can be assured that their needs will be assessed prior to admission into the home. EVIDENCE: Resident’s and or their representatives are provided with clear information about the service prior to making a decision about moving into the home. On discussion with a new resident and their family they confirmed that they had received information from the registered manager when they had visited the home. A copy of the service users guide can be found in all bedrooms. Resident’s are assessed prior to admission to the home to gain details on there, physical, emotional and social care needs. A social history is undertaken and these are continually updated during the first few weeks after admission. A Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 9 new assessment tool has been introduced throughout BUPA homes with the staff at the home nearing completion of the transfer onto the new documentation. It was evident that the registered manager has been quality checking the information to ensure that the system meets the needs of residents. All residents are encouraged to visit the home prior to admission. National Minimum Standard (NMS) 6 was not assessed, as intermediate care is not provided in this home. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, (Older People) and (6,9,16,18,19,20 Adults 18-65) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to ensure that resident needs can be met within the home and demonstrate how risk are minimised. Clear medication audit trails do not ensure that residents are protected. EVIDENCE: Care plans were seen on the files seen as part of the case tracking process. They clearly instruct the carers on residents preferences and what support they require. Care plans are reviewed on a regular basis or as needs changed. The Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 11 care of one resident case tracked had changed and it was noted that new plans and a risk assessment had been completed to ensure their safety. Risk assessments for supporting people with their behaviour need to be developed and detail how carers can minimise risks for resident, their peers and carers. The changes to the home environment have assisted the staff in how they observe the interaction between residents at the home and they are able to respond more effectively. In reviewing the incidents and records at the home it was evident that carers require training on how to positively support residents that challenge so that risks are minimised. Resident’s weights are recorded alongside health care checks. There is good communication with healthcare professionals. Food and fluid intake charts are used where it is essential to monitor resident’s needs where risks have been identified. The medication recording system does not meets the guidelines set out by The Royal Pharmaceutical Society. A record on the amount of tablets carried forward to the next month on medication only used as required was not indicated on the new MAR sheet (Medication Administration Record). A requirement is made for the recording of the medication stock control system to be reviewed. It was also noted on one of the files reviewed that important information relating to an allergy to specific medication had not been transferred to the new documentation that would support a resident if and when they required admission to hospital. A requirement is made for the registered manager to take appropriate action. All changes to medication were verified by the GP with a printout being faxed to the home. Medical histories are also available within the files. Controlled drugs were found to be stored appropriately and were always signed by two staff. Evidence was available in staff files that medication training had been completed and certificated. During the inspection care practices were seen to be respectful and demonstrated a person centred approach. All comments from residents were positive in that care needs were always met. In discussion with relatives visiting the home they confirmed that they had no concerns about the support their family member was receiving. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Older People) and 12,13,15,17 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities within the home are not always developed around resident’s preferences and needs. Relatives and visitors are warmly welcomed within the home. Meals are varied, home cooked and attractively presented. EVIDENCE: The homes atmosphere is friendly and warm with good indoor and outdoor communal space in which residents can relax. Activities do not meet the needs of residents that have a dementia. In discussion with the registered manager it was evident that this area of need had been identified and that the activities Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 13 organiser was to concentrate on the development of individual and group activities to extend what was on offer at the home. Resident’s have the choice of music or TV in the lounge or in their bedrooms. Some residents choose to spend time in their own rooms where they can be quiet. Carers undertake monitoring checks and were seen to take drinks throughout the day. The service has a dedicated activities organiser who is developing the activities within the home. They along with several carers are undertaking training specifically in supporting older people with a dementia with appropriate activities. Residents were actively encouraged and supported to maintain their independence and links with family and the local community. Meals at the home are freshly cooked and attractively presented. Portions were seen to be adequate and residents were offered more if required. A choice of sweets is offered. Resident’s spoken with said they enjoyed the meal and were offered a choice if they did not like the meals on the menu. Residents can choose to eat their meals in their rooms. It was observed that individual support is given to resident’s that need assistance with their food. Carers were seen to be respectful and attentive to individuals. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 (Older People) and 22,23 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that any concerns that they raise will be taken seriously and fully investigated. Care practice within the home ensures that resident’s are protected EVIDENCE: A complaints policy is available within the home and both residents and their relatives know who to discuss their concerns with. There has been one complaint since the last inspection. The provider has investigated this complaint. No evidence was found to substantiate the complaint. The registered manager has been asking for feedback from the investigation into as to the circumstances of a fall of a resident whilst they were in hospital. The resident has now returned to the home and is presently nursed in bed, as they are not weight bearing. Risk assessments are in place to protect the residents. All carers undertake vulnerable adults training to ensure that residents are protected and rights are maintained. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 (Older People) and 24,30 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in a clean and well maintained home. EVIDENCE: Since the last inspection major work has been completed to extend the facilities on the first floor of the home. More communal area is available and an observation area has been built into the nurse’s station to enable carers to respond effectively and timely in supporting residents. It was noted that the atmosphere was more relaxed due to more room being available. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 16 The home has also been redecorated. In touring the building all communal areas were seen to be clean and well maintained. Bedrooms were personalised, with many resident’s bringing treasured items from home. A team of housekeeping staff cleans the premises daily. Carpets are cleaned on a regular basis sometime several times a week if accidents occurred. The inspector found no trace of offensive odours at the home. In discussion with the one of the housekeeping employees they confirmed that there is a hygiene routine in the home with toilets and bathroom being checked several times a day. Satisfactory reports from the fire and environmental health departments’ were available for inspection. There is a dedicated laundry area that meets the needs of residents. One resident said that the standard of laundry was very good. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 (Older People) and 32,34,35 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good recruitment procedures ensure that residents are protected. The staff team need additional training to ensure that the behavioural needs of residents are fully met. EVIDENCE: On the day of the inspection it was seen that the staffing ratios meet standards. In addition to the care team two housekeeping staff, and a cook were working in the home. Staff files viewed all demonstrated that relevant employment checks had been completed. A Protection of Vulnerable Adults check is always completed for all new staff followed by a disclosure for the Criminal Records Bureau (CRB) check. Existing employees also have CRB checks. The provider continues to promote training in the home. Files confirmed that induction training is completed for all new staff and that statuary courses are Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 18 undertaken. Specialist training has been undertaken to meet the needs of residents that have a dementia. However it was apparent that for one resident case tracked that their needs in supporting their behaviour were not being met especially at night. In discussion with the deputy manager and later during the feedback to the registered manager it was confirmed that that discussions were in progress to identify appropriate training to meet this need. A requirement is made to ensure that this need is met. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 (Older People) and 37,39,42 (Adults 18-65) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the home is managed in their best interests. EVIDENCE: Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 20 It was evident that the registered manager was quality checking the system in place at the home, especially with the introduction of the new recording system. The views of residents and their families are sort by the use of biannual surveys that inform the development plan of the home. A system to maintain health & safety within the home is maintained by the registered manager and supported by the maintainer. Good documentation was available. This ensures residents are safe, listened to and that the service is managed in there best interests. Staff appeared to be well supported but there is no evidence that they receive supervision as set out in the national minimum standards. A recommendation is made for the registered manager to review how the standard can be met. Daily records seen were well maintained and monitoring was notable. Residents’s cases tracked or spoken with maintained their own finances or were supported by relatives. The views of residents and their families were sought twice a year through a survey. A report complied from the findings was included in the AQAA information received by the inspector. BUPA has developed and reviewed many of their policies over the past year and improved how they monitor quality. Their senior managers maintain good communication on the developments within BUPA with CSCI through the provider relationship managers at the commission. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 21 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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 OP9 Regulation 13 Requirement The system of recording medication and stack controls needs to be reviewed to ensure that there is a clear audit trail. That critical information relating to residents is recorded/ transferred to new documentation to ensure that residents are protected. That carers receive appropriate training in the management of challenging behaviour to ensure the safety of residents and carers Timescale for action 30/09/07 2. OP8 13 30/09/07 3. OP30 13 31/10/07 Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 YA5 OP36YA36 Good Practice Recommendations Care files need to contain a contract signed by the resident and or their representative. The manager needs to ensure that all staff members receive supervision at least six times per year. Acacia Lodge Nursing Home DS0000029163.V346709.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 DS0000029163.V346709.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!