Inspection on 29/07/05 for Acorn Grange

This inspection was carried out on 29th July 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 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 Grange 20/01/10

Acorn Grange 04/03/09

Acorn Grange 05/12/06

Acorn Grange 16/01/06

Acorn Grange 07/03/05

Acorn Grange 02/09/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Acorn Grange Vicarage Road West Cornforth Durham DL17 9JW Lead Inspector Jean Pegg Unannounced 29th July 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. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Acorn Grange Address Vicarage Road West Cornforth Durham DL17 9JW 01740 656976 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) Manor Care Home Group CRH 59 Category(ies) of DE(E) Dementia - Over 65 - 19 places registration, with number OP Older Persons - 40 places of places Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2005 ( Announced) Brief Description of the Service: Acorn Grange is registered to provide residential accommodation for older people including nineteen people with dementia. Acorn Grange provides services for up to fifty nine people including day care. The home is situated in its own grounds which includes parking and colourful borders to the front and large lawned areas to the back of the building. Inside the home provides single bedroom accommodation over three floors. A passenger lift enables access to the upper floors. Only one bedroom has ensuite facilites. The home also has two conservatories, two dining rooms and several lounges. Acorn Grange is situated off a main street in West Cornforth, providing good access to local shops, and social facilites. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Friday July 29 and lasted for six and a half hours. This was the first inspection taken with the newly appointed manager of the home. Four service users, one relative and four staff were spoken to. Three service users, five relatives and one visiting professional completed comment cards. These are some of the things that were said at the time of the inspection, written in thank you cards sent to the home, and included in comment cards completed just after the inspection: “From the time that (name) entered Acorn Grange ….the attitude, dedication, discipline and the wonderful caring has just been so professional, with a lovely personal warmth from you. This helped to make her stay pleasant and comfortable…” “I am always made welcome and staff are always ready to answer questions and give information.” “Not enough staff to cope, not enough tea in the day, old people like plenty of tea and coffee.” “The staff spoil me rotten!” “Staff always let me know if she has had an upset night” Of the three service users that returned comment cards, all three said that they liked living there and that they felt well cared for. Of the five relatives that completed the comment cards, all five said that they were satisfied with the care provided. Generally this inspection was quite positive with the home fully meeting all but one of the standards assessed. What the service does well: The home assesses people before they are admitted to the home so that plans can be made about how their needs will be met. Individual plans of care are written for service users and these plans are checked regularly to make sure that they are still relevant. Service users are able to see different health care specialists when they need to such as doctors, district nurses, community psychiatric nurses, opticians, chiropodists etc. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 6 The home has checks in place to look after service user medicines safely. Service users said that staff in the home respect their privacy. The home has a complaints procedure in place and most people know how to make a complaint. The home remains suitable for meeting service user needs and has recently been redecorated and furniture renewed. The home is clean does not have any unpleasant smells. The staffing levels within the home are satisfactory and are generally enough to meet the care needs of service users. The home carries out checks on staff before they are employed to work there. 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. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Pre admission assessments are completed for new service users and care plans are written on the basis of these assessments. EVIDENCE: Four service user files were checked. There was evidence of social services care management assessments and care plans and also copies of the homes own assessment documents. The most recently completed assessment documents seen comply with the national minimum standard requirements for information. Care plans written by the home were in place in service user files. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 9 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 Individual plans of care are written for service users describing how health, personal and social care needs are met. Service users have access to a range of different community health care specialists to help meet their assessed needs. The home has safeguards in place to deal with service user medicines safely. Service users privacy is respected. EVIDENCE: Four service user files were checked. For each service user individual care plans were in place and there was evidence of these plans being reviewed on a regular basis. Of the four plans only one had evidence of a signature to say that the care plans had been written with the service user or their representatives’ agreement. Of the comment cards completed by relatives, all five state that they are kept informed of important matters affecting their relatives and that they are consulted about decisions affecting their care. Service user files show that service users have access to different health care specialists for example GP’s, the district nurse, chiropodist and community psychiatric nurses. The manager has been trained by the primary care trust to Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 10 undertake continence assessments and Vision call visit annually to check eyesight. Nutritional screening is undertaken and service user dietary likes and dislikes are recorded. One service user had a care plan in place for the treatment of a pressure sore. A visiting professional who completed a comment card stated that “foot care is provided by the home and they are doing a good job.” One relative stated, “My sister is well looked after.” Medication records were checked and were found to be satisfactory. Service user care plans state whether or not service users self medicate. On this occasion, none of the service users had chosen to look after their own medication. The home has a record of who is trained to administer medication and evidence of their training was available for checking. The manager audits service user medication and staff record keeping on a weekly basis. Service user and relative comment cards show that the home respects service user privacy and are thought to treat service users well. One relative commented that “I am always made to feel welcome and staff are always ready to answer questions and give information” Care plans indicate the preferred name to use when speaking to service users. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 11 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) 13 Service users maintain contact with friends and relatives. EVIDENCE: At the last inspection, it was recommended that the home provide service user relatives with written information about the home’s policy on maintaining involvement with service users. The manager said that relatives now get a copy of the service users guide, which has this information in. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 12 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 Generally, service users and relatives know how to make a complaint. EVIDENCE: The home has a complaints policy and procedure, which is on display within the home and a copy, is included in the service users guide. Two of the service user comment cards and four of the relative comment cards said that they knew how to make a complaint. One relative said that they had made a complaint. The complaints book was seen and the last recorded complaint was in February 2005. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 13 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 The home remains suitable for it’s stated purpose and there is evidence that the home has been recently redecorated and furniture renewed. The home is kept clean, pleasant and hygienic and there are procedures in place to control the spread of infection. EVIDENCE: A walk around the building showed that a lot of redecoration has taken place recently, which has made the home look nicer. Some new furniture has been bought for example television and video player, dining room furniture, bedroom furniture and a lot of chairs have been reupholstered. The manager said that all but five service user beds have been replaced and floor coverings and tiles have been replaced in some rooms. Outside, the gardens are tidy but mainly laid to lawn. The manager stated that the gardener had plans to redesign the garden to take account of the sensory needs of service users. The plans include putting in pathways, and colourful and aromatic flowerbeds. The home was generally clean and tidy. The home has systems in place to control the spread of infection for example soluble bags are used for soiled linen, washing machines have the appropriate washing settings, infection Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 14 control polices are in place and staff are provided with protective clothing. Staff spoken to were able to describe how to handle soiled items and clinical waste correctly. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 15 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 The rotas show that there are sufficient staff on duty to meet the general care needs of service users The recruitment practices within the home are generally satisfactory. EVIDENCE: Rotas show that there are usually four and sometimes five staff on duty in the residential unit and between three and four staff on duty in the EMI unit. In total there are usually five staff on duty during the night. These staff are supported by the manager, domestic, catering and maintenance staff. Three relatives indicated on their comment cards that they felt that there were sufficient staff on duty, one said no and one said on most occasions there was sufficient staff. The manager said that she was not restricted in the number of staff on duty. The recruitment file of a new member of staff was seen and found to be satisfactory. There was no evidence to indicate that staff were provided with copies of the General Council For Social Care codes of practice. Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 16 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) None None of these standards were assessed. EVIDENCE: Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 17 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 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 x 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 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x x Acorn Grange B54 S7611 Acorn Grange V234348 290705 Stage 4.doc Version 1.40 Page 18 No 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 29 Regulation 18 (4) Requirement The registered person must make arrangements for providing persons who work at the care home with informationabout any code of practice published under section 62 of the act. Timescale for action 30th September 2005 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 7 Good Practice Recommendations The registered person should ensure that individual care plans are agreed and signed by the service user whenever capable and / or representative if any. 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