Inspection on 04/04/05 for Acacia Lodge Nursing Home

This inspection was carried out on 4th April 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acacia Lodge Nursing Home 18/04/07

Acacia Lodge Nursing Home 13/07/05

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 Name Acacia Lodge Nursing Home 1 Stanhope Road Croydon, Surrey CR0 5NS Lead Inspector Michael Williams Announced 4th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Name Version 1.00 Page 3 SERVICE INFORMATION Name of service Acacia Lodge Nursing Home Address 1 Stanhope Road, Croydon, Surrey, CR0 5NS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8688 8000 020 8667 1060 jag@lrh-homes.com London Residential Healthcare Limited Mrs Ellen Teresa Ryan Care Home including Nursing care 30 Category(ies) of Old Age; 30 registration, with number of places Conditions of registration Date of last inspection None 22/9/04 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. Name Version 1.00 Page 4 SUMMARY This is an overview of what the inspector found during the inspection. The home’s philosophy, described within their Statement of Purpose, is “to provide a homely atmosphere and a high standard of nursing care”. There are both trained nurses and carers on duty twenty-four hours a day and a full time Activities Organiser leads a varied programme of activities. This was the first inspection (announced) to be conducted during the year 2005/06. During this and subsequent inspections key standards affecting the safety and well being of service users will be assessed. What the service does well: What has improved since the last inspection? What they could do better: The manager has resolved to make some minor changes in respect of fire safety following the advice of the Fire Safety officer; this includes extending the use of magnetic door holders instead of door wedges. The manager will also ensure that the home’s fire risk assessment is checked monthly to confirm it remains up to date as advised. The manager intends to review the accessibility to bathroom and toilets to ensure they are accessible and within easy reach of service users. The manager also needs to ensure all new staff are subject to a new police, (Criminal Records Bureau [CRB]) check when recruited. Name Version 1.00 Page 5 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Name Version 1.00 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Name Version 1.00 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Service users have a comprehensive assessment carried out by the staff prior to their admission, which ensures that staff are able to meet their needs. Service users or their relatives where possible are involved in the identification of their care needs and planning how the staff will met them. EVIDENCE: Service users case files were checked. Carers, nursing staff and ancillary staff assisted in the assessment of this standard as did the manager (who is herself a Nurse). The service users and their visitors also assisted in confirming the findings. All prospective service users have a full assessment prior to admission and a trained Nurse - using an assessment tool, conducts this. Each service user then has an individual and comprehensive care plan - drawn up in collaboration with the service user if this is possible or their relatives if it is not. These care plans are reviewed regularly, at least monthly to confirm they remain appropriate, and more comprehensively from time to time. A service user who has recently moved into the home confirmed that their needs had been evaluated as described. Name Version 1.00 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 8 9 10 As indicated in the previous section all care and health needs are assessed prior to admission and reviewed and revised periodically. This ensures that home staff are able to meet service users’ health care needs as and when they change. EVIDENCE: Samples of service users’ case files were examined. These files demonstrate that service users have a comprehensive plan of care. A commercially available standardised recording format is in use. It was evident that service users and their relatives have been encouraged to be involved in the process of drawing up these plans of care. Service users rarely self-medicate but the home can accommodate this if it is the service user’s wish and they have the capacity to do so safely. Service users confirmed that staff respect their rights to privacy and dignity when receiving care and support. Service users have access to all those community based health services available to the wider community including General Practitioners, hospital clinics, chiropody, optometry and specialist nursing service such as the ‘tissue viability’ service (for skin care). Whilst no errors in the administration of medication were identified it is recommended that when medication is not being delivered in dossette packs then the number of tablets is entered on the medication chart to enable auditing of medication. Name Version 1.00 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 The home provides a congenial setting which is comfortable, quiet and peaceful 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 opportunity to maintain contact with family and friends and the community. EVIDENCE: The service users stated and the inspector noted that family and friends visit the home regularly. Whilst there is no visitor’s room (for service users who share a bedroom) there are a number of rooms such as the office, which could be used for private meetings. Choices are typical of this type of home, for example in respect of care planning, medication, meals, clothing, daily activities, religious observance and so forth. An activity programme is available for those service users who choose to take part and on the day of inspection the training officer for the home was delighting service users with his rendition of favourite old songs. Service users find the meals to their liking and are looking forward to the revised summer menu. The record of meals shows them to be a varied and wholesome selection and includes special diets. The kitchen was in good order when inspected both by the Environmental Health officer and the CSCI inspector. Name Version 1.00 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The owners, manager and staff have a positive approach and attitude to service users concerns, complaints and suggestions, which enables service users to feel free to make observations, both positive and critical ones. Procedures and staff training for the protection of vulnerable adults have been introduced to ensure service users are protected from abuse. However not all new staff have new and up to date Criminal Record Bureau checks. EVIDENCE: The record of complaints was checked; the suggestion and feedback book in the dining room was checked; some service users and relatives gave written feedback (12 in all). Policies and procedures are in place for complaining ad dealing with allegations of abuse; training for staff is in place; a complaints leaflet is readily available in the home’s lobby. Only one complaint is recorded for the previous 12 months and this was investigated by the CSCI directly and was found not substantiated. The home has copy of the local authority’s procedures for dealing with the protection of vulnerable adults and staff are giving training about this important matter as part of their induction. Staff files show that not all staff have undergone a new police check by home. Name Version 1.00 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 Service users and visitors appreciate this large and well-maintained building, which provides them with a pleasant and comfortable home environment and is clean and odour free. Many rooms have ensuite facilities which is particularly important to service users. EVIDENCE: The inspector toured the building including ground and first floors and the garden and cellar. Service users offered their opinion of the premises – they think it a fine building with pleasing outlooks. The grounds are well maintained and the spring flowers looked most attractive. The building is in a good state of repair and the on-site maintenance person is available to deal with damage and breakages. There is a mixture of single and double rooms and many have ensuite facilities. The home was at comfortable temperature on the day of inspection and there were no complaints about the temperature of the home at other times. The staff, including ancillary staff, receives training in health and safety including the control of chemicals, handling and manoeuvring service users and general matters of safety for service users. Name Version 1.00 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 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 . Not all new staff have Criminal Records Bureau check, which could compromise the safety and well being of service users so a requirement is made to address this matter. EVIDENCE: The Registered Manager was confident that the home would have at least fifty percent of their staff to National Vocational Qualification Level 2, or its equivalent, by 2005 and this is now the case. The home’s manager has also completed an NVQ at level 4. The home routinely employs two “adaptation nurses”, that is nurses from overseas undergoing transition training, at any one time. The home employs such staff as carers and their previous qualifications and experience rank them as care (not nursing) staff having ‘NVQ 2 equivalent’ training. The manager confirmed that if staff that are recruited have a recent police check the home is not obtaining a new up to date one as required. The company employs a training officer and his records show that staff undertake a comprehensive range of induction and training including matters of health and safety, fire safety, infection control, manoeuvring and handling, and the personal care of service users. Regular staff meetings and periodic individual staff supervision is provided. Name Version 1.00 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,38 This is a well managed care home; the home has a competent nurse/manager and the owners are clearly dedicated to providing a high standard of care. Service users’ needs are a key consideration to the running of the home and their care and well being is seen as paramount. There are a number of matters requiring attention including matters of fire safety these include risk assessments and door holders as well as locks on fire escape route. EVIDENCE: Using the National Minimum Standards this home has consistently demonstrated a professional and well organised approach to the provision of care and is clearly run with the best interests of the service users uppermost in everyone’s mind. Supporting evidence comes from the manager’s qualifications as nurse and her achievement of a National Vocational Qualification at level 4. Policies and procedures are in place; a methodical system for recruitment, training and staff support is in place. The Directors make their monthly visits and reports to monitor standards in their home. A number of fire safety matters are listed in the requirements table. Name Version 1.00 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Name Version 1.00 Page 15 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 19 Regulation 19(4)(b) Requirement staff recruitment: The home must obtain for each member of staff the documents specified in Schedule 2 - includng a police (CRB) check and a protection of vulnerable adults Act list (POVA) check. Fire Safety: the home must provide a suiable door locks on the bedroom that form a fire escape; door wedges must be replaced with magnetic holders and emergency lighting must be checked monthly. Timescale for action 30/6/05 2. 38 23(4) 30/6/05 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. 2. Refer to Standard 9 38 Good Practice Recommendations Medication: it is recommended that when medication is not delivered in a dossette pack the number of tablets is noted on each medication chart at the start of each month. Environment: it is recommeded that a safety Yale-type lock is fitted to the cellar to ensure egress is not impeded. Name Version 1.00 Page 16 Commission for Social Care Inspection 8th Floor, Grosvenor House 125 High Street Croydon, Surrey CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Name Version 1.00 Page 17 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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