Inspection on 28/11/07 for Acorn Close

This inspection was carried out on 28th November 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.

Other inspections for this house

Acorn Close 05/05/09

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Acorn Close Sullington Road Shepshed Loughborough LE12 9JG Lead Inspector Andrew Sales Unannounced Inspection 28 November 2007 10:00 th DS0000070371.V349417.R01.S.doc Version 5.2 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 DS0000070371.V349417.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 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. DS0000070371.V349417.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Close Address Sullington Road Shepshed Loughborough LE12 9JG 01509 504279 01509 504279 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) Prime Life Ltd Miss Carmen Rosende Care Home 23 Category(ies) of Learning disability (23), Mental disorder, registration, with number excluding learning disability or dementia (23) of places DS0000070371.V349417.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection This is a new service. Brief Description of the Service: Acorn Close is a newly built residential care home for a maximum of 23 people who have either mental health illnesses or learning disabilities. The home is purpose built. The home is located in Shepshed, Leicestershire and is close to the town centre and local amenities. The fees for the service start at £550.00 per week. More information is available in the Service User Guide available at the service. DS0000070371.V349417.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 for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. Where possible, we include evidence from other sources, notably District Nurses and Social Workers. We also use information gathered throughout the year, to support our judgements. This may include notifications from the provider, complaints or concerns and the pre-inspection questionnaire, which the provider is required to complete prior to a visit to the service. This inspection was unannounced and took place on 20 November 2007. On the day of the inspection there were seven residents in residence. The provider submitted the pre-inspection documentation, which has also provided evidence for us to make informed judgements when assessing the National Minimum Standards (NMS). The primary method of inspection used during the visit to this service was ‘case tracking’. This involved selecting three residents and tracking the care they receive through review of their records, discussion with them where possible, the care staff and observation of care practices. On the day of the visit we were able to speak with one resident at length, two residents briefly and make observations of daily life. We also spoke with two members of the support staff who were also very helpful. We spent part of the day discussing records, documents and policies with the manager. All of the key standards were inspected on this occasion. What the service does well: The manager and support staff have a very good understanding of the needs of the residents living at the home and care plans record the needs of residents in clear detail. Risk assessments are also informative for staff, which is important for promoting the safety and independence of residents. There are good methods of communication between staff, which means that staff are up to date with when residents needs have changed and when tasks need doing. Staff who spoke with the inspector are clearly committed to promoting the quality of life of residents. The manager ensures that specialist professionals DS0000070371.V349417.R01.S.doc Version 5.2 Page 6 are called upon for their input on how to best meet the needs of people that live at Acorn Close. Staff support residents to maintain contact with family and friends. The structure and culture within the home is that of putting resident’s needs and independence first. The staff group ensure that residents are actively engaged in getting out and getting involved in day-to-day events and activities. There is an appropriate complaints procedure in place and staff are encouraged to act on behalf of residents to enable residents to access this procedure. Staff demonstrated an understanding of their responsibilities in protecting residents from abuse. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000070371.V349417.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000070371.V349417.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully assessed before moving in to the home. Care planning is thorough and enables clear action plans to be developed for residents to fulfil their own potential. EVIDENCE: The files we looked at contained assessments conducted by the manager and the relevant referring agencies. All of the assessments and care plans were comprehensive and contained sufficient information to enable staff to ensure that they could meet the residents assessed needs. There were detailed action plans for support staff. The manager and staff spoken with explained how they used information on these plans and how they were regularly updated to reflect changes in residents needs, preferences and behaviour. DS0000070371.V349417.R01.S.doc Version 5.2 Page 9 DS0000070371.V349417.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place for ensuring that individuals’ needs and choices are met and that residents can participate in their chosen activities safely. EVIDENCE: The care plans we looked at cover aspects of social, emotional, health and personal care needs. The residents present have only moved in to their accommodation since August and there is evidence to show that evaluation of their progress has been undertaken. Staff said plans would be evaluated on a regular basis in order to identify if any changes are necessary. Staff spoken with demonstrated an excellent understanding of the purpose of care plans and a good awareness of the individual needs of residents, as reflected in the written plans. DS0000070371.V349417.R01.S.doc Version 5.2 Page 11 Care plans detail individual needs and balance the risk involved for that resident in day-to-day living activities. Residents are supported to go out regularly to engage in variety of different activities. Communication needs are identified clearly in resident plans. Visual tools such as pictures and photographs may be used to enable residents to make choices and decisions about their lives. Staff spoken with gave examples of residents choosing activities, holidays and meals. Care plans and staff provided clear evidence of how residents interests are put first. Support is flexible enough to enable residents to make spontaneous decisions about what they did and where they wanted to go. Residents are clearly supported to make informed and spontaneous decisions in their daily life. Staff were observed with residents discussing choices throughout the day and during meal times. Positive relationships and interactions were also observed between residents and staff. Most residents have some comprehension of their care plans and assessed needs. The manager reports that the consent and involvement of relatives or advocates is sought and evidence of this involvement is recorded on care plans. DS0000070371.V349417.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are committed to promoting residents’ rights and enabling residents to experience a fulfilling lifestyle. Residents are offered a varied and healthy diet. EVIDENCE: During our visit some residents were either out at college or undertaking other daily activities in the community. Routines at the home are flexible, residents were observed carrying out individual tasks. Staff respect the rights of residents and they ensure residents’ privacy is maintained, for example always closing the door if assisting with personal care. Residents spoken with stated that staff knock on their bedroom door before entering. DS0000070371.V349417.R01.S.doc Version 5.2 Page 13 Interaction between staff and residents was positive, staff involved residents in discussions speaking to them in a respectful manner. Staff support residents to use local facilities including going to the local pub, holidays, shopping and going into the city centre. One person told us how he is able to attend musical events and socialise in a manner of his choice. He said ‘the staff and manager are very helpful, I like to help them out too. I am out a lot though.’ Residents spoken with confirmed that they took part in the different social activities arranged with support from staff, which they enjoyed. Residents told us they are able to go out and visit relatives and receive visitors. Records show how residents are consulted with and what their favourite activities and meals are. We observed two residents exercising their choices during the day. The menu records show that residents always have a choice and that varied healthy nutritious meals are offered and that dietary needs are catered for. The menu is planned in consultation with residents who also may assist with the shopping. Food storage and preparation areas were clean and organised. fridge and food temperatures were monitored and recorded. Residents commented that they enjoyed the food. DS0000070371.V349417.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s policies and procedures for dealing with medicines and receive their personal support as they prefer and require. EVIDENCE: The residents’ files show that specialist healthcare professionals such as psychiatrists and clinical psychologists are accessed when necessary and that residents go for regular health checks. All healthcare appointments are recorded on the care plan, which shows that residents have access to chiropody, dentist and to practice nurses. The care plans include guidance of how to promote independence and the right to make choices for example with clothing and developing self-image. Staff gave excellent examples of how they respect individual’s wishes, choices and emotional needs and how they have developed innovative ways of communicating with different residents. DS0000070371.V349417.R01.S.doc Version 5.2 Page 15 There is evidence that the staff team is already well established and trained and the collective experience of all the team ensures the residents are treated in a manner that is appropriate for them. There is evidence on care plans that physiotherapists and occupational therapists advice has been obtained on how to best meet the needs of residents and where possible this has informed changes to care plans and the way support to residents is given The management of medication appeared well organised and the medication administration record (MAR) contains a medication profile for each resident and any possible side effect that maybe experienced. Prescribed medicines are already pre-dispensed in monitored dosage systems (MDS). Instructions for the administration of medication were clear and the medicines we checked in the MDS have been given as prescribed. We saw evidence that staff responsible for administration have received appropriate training. We saw new risk assessments for each medication each individual was taking. These were very detailed and provided clear guidance for staff. This will contribute greatly to the effective management of medication and help reduce risks for residents and staff. DS0000070371.V349417.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel they are consulted and their views listened to and acted upon. Systems are in place to safeguard people from abuse. EVIDENCE: Staff spoken with had a good understanding of the importance of enabling residents to voice their complaints. We spoke with three residents who said that they would speak to the manager if they were not happy with something. We have received no complaints regarding this service and have no concerns in this area. We saw clear policies and procedures for staff to follow in the event of a complaint. Staff spoken with stated they had received training in safeguarding adults and had a clear understanding of what constituted abuse. They were clear of what responsibilities they had to ensure residents remained safe. Residents spoken with said that they felt safe in the home and staff were pleasant to them. DS0000070371.V349417.R01.S.doc Version 5.2 Page 17 DS0000070371.V349417.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and personalised by individuals living there. Residents live in comfortable surroundings. EVIDENCE: Acorn close is purpose built and only recently opened. We looked at all of the communal areas and found them to be well furnished and maintained. Although the floors are laid with laminate, they do not appear institutional, the home has a modern and domestic appeal. Three residents told us they liked the homes décor and furnishings. We looked at bathrooms, bedrooms and communal areas including lounges and the kitchen. These are all well kept, clean and free from any odours. DS0000070371.V349417.R01.S.doc Version 5.2 Page 19 Bedrooms are personalised and provide residents with a pleasant space to relax in. We saw effective cleaning schedules in place, good laundry facilities and effective management of hazardous cleaning materials. DS0000070371.V349417.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who are competent and qualified. Residents are safeguarded by the homes recruitment and training procedures. EVIDENCE: Staff files contained all relevant recruitment documents. The manager confirmed that thorough pre-employment checks are carried out. Staff also told us that all these recruitment procedures had taken place. The rota demonstrated that adequate staff are allocated to enable residents to go out regularly during the week. The staff we spoke with, demonstrated a sound understanding of their roles and responsibilities and a great insight into the methods of promoting independence whilst supporting people with mental health issues. They told us that they had attended numerous training courses and have regular updates in DS0000070371.V349417.R01.S.doc Version 5.2 Page 21 the mandatory Health and Safety training courses. They said all of the necessary mandatory training is provided and there is the opportunity to go on other courses if it enables staff to carry out their roles more effectively and efficiently and will ultimately benefit the residents. There was evidence on staff files of regular supervision sessions taking place. Staff said they felt extremely well supported by the manager in all aspects of their work and with other issues as well. DS0000070371.V349417.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well managed service. People benefit from the systems that are used for monitoring and reviewing the quality of care. The health, safety and welfare of people is promoted and protected. EVIDENCE: The registered manager is an experienced home manager and has transferred from another service operated by Prime Life. She is well respected by residents and staff alike and is developing a service where resident’s well-being and dignity is a priority. She has completed the Registered Managers Award, a qualification required under the National Minimum Standards (NMS). DS0000070371.V349417.R01.S.doc Version 5.2 Page 23 Staff said they felt the home was well run and the manager was always on hand for support and advice. Staff spoken with said the manager is approachable to discuss any issues. We saw evidence of reviews, meetings and consultation carried out with individual people. The staff who spoke with the inspector, confirmed they receive regular supervision and attend regular team meetings. Staff confirmed that this is part of a supportive management style provided by the manager. All of the staff files showed us that they have undertaken training in mandatory health and safety subjects and subjects specific to the needs of residents living there. Staff spoken with, were aware of health and safety procedures and commented positively on the training provided. Risk assessments were observed on individual files and are in place for the building and individual people. Records for Health and Safety monitoring and the servicing of systems and appliances were inspected on this occasion and were found to be up to date. DS0000070371.V349417.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000070371.V349417.R01.S.doc Version 5.2 Page 25 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. 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. Refer to Standard Good Practice Recommendations DS0000070371.V349417.R01.S.doc Version 5.2 Page 26 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. 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