Inspection on 05/12/06 for Acorn Grange

This inspection was carried out on 5th December 2006.

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 16/01/06

Acorn Grange 29/07/05

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 Acorn Grange Vicarage Road West Cornforth Durham DL17 9JW Lead Inspector Jean Pegg Unannounced Inspection 5th December 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Grange Address Acorn Grange Vicarage Road West Cornforth Durham DL17 9JW 01740 656976 01740 656667 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) Manor Care Home Group Melanie Dawn Clarke Care Home 48 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (29) of places Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Acorn Grange is registered to provide residential accommodation for forty-eight older people including nineteen people with dementia who are over the age of sixty-five. Acorn Grange is not registered to provide nursing care. The home is situated in its own grounds. The grounds include parking spaces and colourful borders to the front and side of the building 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. Two bedrooms have en-suite facilities. The home also has two conservatories, two dining rooms and several lounge areas. Acorn Grange is situated off a main street in West Cornforth, providing good access to local shops and social facilities. Fees for this home are: £364:50 for general residential care and £417 for dementia care. Additional costs include hairdressing, private chiropody, toiletries and personal items including clothing, newspapers and magazines and door guards. Fees are reviewed biannually on April 1st and October 1st. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted for eleven hours. This inspection involved visiting the home and looking around the building; talking to four service users, one relative and three staff; sending out questionnaires to service users (of which eight were returned) and relatives (of which seven were returned) and twelve other health care professionals who have contact with the home, (of which nine were returned). Documents and records held at the home were also looked at. In particular, as part of this unannounced inspection, the quality of information given to people about the care home was looked at. Four people resident at the home were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk What the service does well: Acorn Grange has information about the home available for service users. The information includes details of how much it charges for people to live there. Service users are given contracts that say what the fees are and what they include. It also says how fees should be paid and how often they should be paid. All service users have their needs assessed by the manager before they are admitted into the home. Service users have care plans that describe how their needs will be met. Care plans are signed by service users to show that they agree with them. A range of different heath care professionals who visit the home meet service users’ health care needs. These include doctors, nurses, opticians and dentists. The home looks after service user medication and service users’ privacy and dignity is respected. Service users say that staff are “very helpful” and “very good” and that “the doctor is in attendance when needed.” Service users are helped to take part in the activities that they enjoy. Family and friends are made welcome at the home and service users are helped to make choices and decisions in their life. Meals are nicely presented and service users have helped to devise the menus being followed. A service user who was spoken to said “All meals are good and they always ask if I would like something else if I do not want what is on the menu.” Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 6 Although a little bit dated in design, the home is clean and looked after. One service user said “Decoration doesn’t matter as long as I have a good bed and clean clothes – and I have.” There is a sufficient number of trained staff employed in the home to meet service user needs. Proper checks are carried out to make sure staff are suitable before they are allowed to start working in the home. The home is well managed well and is run in the interests of service users who live there. Service users’ finances are all accounted for. Staff receive regular supervision and appraisals that tell them how well they are doing in their jobs. The health, safety and welfare of service users and staff are promoted and protected as much as possible to make the home a safe place to live and work in. What has improved since the last inspection? What they could do better: The Service Users’ Guide could be printed using a larger print size for those people who may have problems with their eyesight. Service Users’ contracts should be regularly reviewed taking into account recommendations made by the Office of Fair Trading. Although meals are good, improvements could be made to the overall dining experience for general residential service users. In particular considering alternative solutions that would prevent the ‘queuing up’ system that tends to take up a lot of time during the day. A copy of the updated Local Inter-agency Adult Protection Procedures available from the Local Authority or from the Internet should be available for staff to follow. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 7 Problems with bad smells in the home should be dealt with quickly to avoid any unpleasantness for service users. Staff supervision records should be signed by both the supervisor and supervisee to confirm that they are true record of what took place. 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. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides information for service users about the home and the fees it charges. Service users’ contracts identify the fees charged and what they include, method and frequency of payment. All service users have their needs assessed by the manager before they are admitted into the home. EVIDENCE: Four service users were asked about the information they received and eight service users responded to questionnaires. Of the four spoken to one service user said that they did not receive a Service Users Guide and two said that they thought they had. A relative present during the discussion confirmed that the home had provided service users with information. Of the eight who returned questionnaires, five said that they had been given enough information Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 10 about the home before they moved in and three said that they had not but qualified this by saying that admission to the home had been on short notice. The Service Users Guide provided by the home is presented in A5 format, which means that the writing is small and may not be suitable for those with visual problems or impairments. The content of the guide complies with National Minimum Standards, but the presentation could be improved to make it easier for those with visual impairments to read. The home manager has produced a Welcome Pack that supplements the Service Users Guide. This Welcome Pack contains some useful information in a question and answer style and includes information about changing costs of care and what is included in the fees charged. It is also printed using a larger font size. The relative who was present during the discussion also confirmed that a representative from head office writes to the service users and or their representatives to inform them about any changes to fees. Only one person spoken to confirmed that they had received a contract, but the manager was able to show signed copies of contracts for all those interviewed. Seven of the eight service users who returned questionnaires said that they had received a contract; the one who said no qualified this by saying that their daughter had it. A copy of the contract given to service users was seen. The contract includes information about trial periods, the fees to be charged and what they include and do not include, when the fees are due for payment and how they should be paid. The contract also makes explicit the interest that will be charged for non-payment of fees and notice periods for both parties. Insurance details are also included. The contract also advises service users to seek independent legal advice before entering into the agreement. The home also has an admission contract, which includes the requirement of a signature to say that the applicant and or next of kin have read the home’s Statement of Purpose and Service Users Guide. All four-service users spoken to confirmed that the manager had visited them either in their own home or at hospital to assess their needs before they moved into the home. There was evidence of pre-admission assessments having taken place in the six service user files that were viewed during the inspection. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have care plans, which are signed by them to confirm agreement. A range of different heath care professionals who visit the home meet service users’ health care needs. The home manages medication in a satisfactory manner and service users’ privacy and dignity is respected. EVIDENCE: Four service users’ files were examined. All of them had evidence of assessments having taken place and individual care plans had been written based on those assessments. Records showed that the manager audits the care plans every month and that care plans are reviewed regularly. Service users’ signatures were evident on care plans confirming that they had been consulted about their care plans. Two different service user’s care plans were examined in detail to establish how health needs are met. The care plans and associated assessments Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 12 identified individual health needs and staff recorded health related issues on a daily basis. Where pressure sores were evident care plans had been put into place and a referral made to the District Nurse. The manager has been trained by the District Nurse to complete continence assessments. Pressure relieving equipment was seen in use. Service users have nutritional needs assessed and foot health assessments are also undertaken. There was evidence of GP, optician, dental and chiropody visits taking place. Twelve health and social care professional were sent questionnaires to complete. Nine were returned, of these eight said that the home communicated clearly and worked in partnership with them, staff incorporated specialist advice into care plans and took appropriate decisions when they could no longer manage the care needs of service users. Seven said that there was always a senior member of staff on duty and that staff were able to demonstrate a clear understanding of the care needs of service users and were generally satisfied with the overall care provided to service users. Seven service users who returned questionnaires indicated that they always received the medical support they needed and one said that they usually did. Comments included “Doctor in attendance when needed” and “The girls get help when I need it.” A senior carer was observed administering medication to service users. This was carried out appropriately. The manager completes monthly audits of medication including stock levels. A copy of the most recent audit was on the storeroom wall. The audit included both positive and negative comments about the audit. The pharmacy that dispenses medication to the home was also due to complete an audit on the monitored dosage system used by the home. Fridge temperatures were taken and recent readings showed an inconsistency in temperatures. In between inspection visits, the manager had both the fridge and thermometer checked and a replacement thermometer was obtained. An audit of four service user’s medicine administration records was completed and the system for managing controlled drugs was also checked. The service users spoken to confirmed that staff look after their medication and made comments like “when they are due they give you them.” and “I get my tablets after meals”. When asked, staff were able to give examples of how service users’ privacy and dignity was observed and service users spoke highly of some staff members who were on duty that day. All eight service users who returned questionnaires indicated that they got the care and support they needed and that staff listened to them and acted upon what they said. Comments included “Very helpful” and “Very Good”. Relatives and other health care professionals confirmed that they could visit service users in private. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to take part in activities of their choice. Contact with families and friends is encouraged and service users are helped to make choices and decisions in their life. Meals are nicely presented and service users have helped to devise the menus being followed. Although meals are good, improvements could be made to the overall dining experience for general residential service users. EVIDENCE: The home employs a dedicated activities coordinator. Unfortunately the coordinator was not present during either of the inspection visits. It was noticed that care staff were still encouraging activities with service users during the coordinators absence. The following comments were taken from minutes of a residents meeting. “Enjoyed chucking ball in net” and “happy doing puzzle books” and “enjoyed the trip to Scarborough”. The manager talked about improvements they would like to make, for example, obtaining sensory stimulation equipment for use with dementia care service users. The Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 14 manager described how the activities coordinator told service users verbally what activities were available and usually negotiated with service users as to what activities they do each day. Activity sessions also included 1:1 sessions for those that do not like group activities. The manager talked about how they had decided to stop following a structured programme of activities each day preferring to be more spontaneous and responsive to service users and their wishes on a daily basis. Service user questionnaires indicate that one service user thinks that there are always activities arranged that they can take part in, five indicate usually and two think sometimes. Of the service users that were spoken to one said “quite a few things go on but I don’t join in much, they’ve asked me to join in but I don’t bother – I’m used to being on my own” and “xxx comes around sometimes and we have a game of dominoes or a quiz. I like them.” Visitors were seen and spoken to during the visits. The seven relatives who returned questionnaire forms said that they could visit in private and this was confirmed through direct observation. The seven relatives also confirmed that they were kept informed about matters affecting their relatives. The manager confirmed that relatives are given information about the home and the minutes of a recently held relatives meeting were available. During the meeting the manager had reminded relatives about the availability of information and how to make a complaint. The home’s Welcome Information Pack answers questions about how service users can maintain independence, autonomy and choice. Service users are encouraged to bring personal possessions in with them and these possessions help to make bedrooms more individual. Service users are also helped to keep control over their financial affairs for as long as they want to do so. After the last inspection visit it was recommended that the plainness of the dining room décor should be improved. The manager has achieved this, through the use of pictures, to good effect. Time was spent in the dementia care unit during lunchtime. It was noticed that the meal of liver casserole was nicely presented with colour being added through the use of fresh vegetables. Service users were also given coloured juice to accompany their meal. This is seen as good practice when caring for people with dementia. The manager described how the service users had influenced the new menus being used. They had contributed ideas for meals they would like to see included and this had been taken note of. The manager also talked about plans to photograph each meal so that the pictures could be shown to service users to help them choose what they wanted to eat. This idea would help some service users who may have reading difficulties or cognitive problems. The dining experience was not so pleasant for service users in the general residential unit. It was noticed that service users have to start ‘queuing up’ quite early to use the lift to access the ground floor dining room. As some service users need wheelchairs or carer assistance to do this it is very time Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 15 consuming and looks to be a tiresome experience. Once downstairs, the dining room is nicely decorated and spacious. All eight service users who completed questionnaires indicated that they always liked the meals provided. Some positive comments were made about the meals provided. “All meals are good and they always ask if I would like something else if I do not want what is on the menu.” “They usually come and ask, some people say I don’t like it, but they would give you something else.” Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which service users, and their relatives are aware of. Staff know how to respond to suspicions of adult abuse, however, this could be improved by ensuring that they have access to the latest copy of Inter-agency Procedures. EVIDENCE: When asked about making complaints in the home, service users said “I would tell my daughter or one of the carers, but I have nothing to complain about!” Another service user named the manager and deputy as people they would speak to. Service users said that they had been given a copy of the home’s Complaint Procedure and a copy was on display in the main entrance hall. As stated earlier, the manger had reminded relatives about the complaints procedure during the relatives meeting. The minutes of this meeting were also on display in the entrance and the manager said that she tried to bring them to the attention of relatives who were unable to attend the meeting. Six of the seven relatives who returned questionnaires said that they were aware of the complaints procedure. Seven health care professionals who returned questionnaires said that they had not received any complaints about the home; the other two who returned questionnaires made no comment. One health care Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 17 professional provided additional written comments that included “I have never had a complaint about this home and the EMI day centre” and “receive daily praise from clients / carers etc.” The record of complaints was seen and the last recorded complaint was May 2nd 2006. The manager said that very often people do not want to make a formal complaint. The possibility of keeping a log of concerns or issues raised that might lead to service improvement was discussed with the manager. The manager has produced a list of actions for staff to follow should they suspect abuse is occurring within the home. This list includes external contact numbers including the police. All staff are expected to complete a twelve week City and Guilds Protection of Vulnerable Adults programme. All Staff including administration and support staff are also required to complete yearly training updates. When asked care staff were able to show that they had knowledge of the procedures to follow if they suspected abuse occurring. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the home is not the most suitable for those service users who live on the first floor, but it is clean and well maintained. EVIDENCE: The home has not had any major structural alterations since the last inspection visit. The manager explained that the decorators were due in to do some work on bedrooms, the kitchen and laundry. New carpets have been ordered for the dementia care unit lounge and corridor. New non-slip flooring has been laid in the bathroom and toilets of the dementia care unit. The garden area for the dementia care service users has been improved and there are plans to extend the garden area. There was some evidence of new furniture in the conservatory areas and some improvement work having been carried out in Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 19 the kitchen following recommendations made by the Environmental Health Officer. Generally the building and its furnishings were in a satisfactory condition with evidence of replacement and renewal taking place. The standard of furnishing provided is clean and functional. There are several lounge / conservatory areas for people to use. Some of the upstairs lounge areas could be described as a little dated in appearance. When one service user was asked about the decoration in the home they replied, “Decoration doesn’t matter as long as I have a good bed and clean clothes – and I have.” Another service user said that they “really liked the decoration.” The only problem noticed was in connection with the layout of the home and the problems it was causing service users who lived on the first floor and who needed to access the dining room on the ground floor. This problem has been referred to in a previous section of this report and a recommendation has been made. Service users were asked about the cleanliness of the home. For those that returned questionnaires, seven said the home was always fresh and clean and one said usually. Comments provided included “all kept clean and tidy”. The service users spoken to were asked how often their rooms were cleaned to which they replied “everyday in hovering, pulling the bed out” and “always spotless, everyday they come in when we go for breakfast, I’m very satisfied.” Generally the home was clean and tidy during the inspection visit. The member of staff spoken to in the laundry had just completed a distance learning programme about Infection Control and was able to describe how dirty linen was handled within the home. The only serious problem noticed during the inspection was a significant odour problem in a particular room. The manager spoke about different approaches they had tried to eliminate the odour. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels within the home are satisfactory and there is a good programme of training in place that means that the home exceeds the national minimum standard for trained care staff. Recruitment practices are good and all the proper checks needed to help protect service users are carried out. EVIDENCE: The home can accommodate up to forty-eight people. Nineteen of these are within the dementia care unit for which there are four staff on duty until 1:30pm and then three staff on duty until the evening and two staff during the night. For the remaining twenty-nine service users in the general residential unit there are either three or four staff on duty during the day, three on duty during the afternoon and early evening and two staff during the night. In addition to care staff there is an administrator, handyman, kitchen and domestic staff, an activities coordinator and a manager. The manager confirmed that there is a senior member of staff on duty at all times. Six of the eight service users who were sent questionnaires said that there is always staff available and two said there were usually staff available. Six of the seven relatives who returned questionnaires said that there was sufficient staff on Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 21 duty. Some of the problems associated with the layout of the home may cause problems with the availability of staff time. This has been described in previous sections of this report. Twenty-nine of the thirty-eight care staff employed at the home have achieved at least National Vocational Qualification Level Two in Care. Six of these staff also have a level three qualification and two have a level four. 76 of the home’s staff have a recognised care qualification. This level of qualified staff exceeds the National Minimum Standard of 50 . The files of staff recruited since the last inspection were checked. They were all in good order and records show that the correct checks including references and criminal record bureau checks had been made before they were allowed to start working at the home. The manager has implemented training programmes that have new staff working towards the achievement of the new Common Induction Standards. The manager has compiled work sheets based on those standards for staff to complete. The staff spoken to confirmed that training took place in the home. One said “yes too much sometimes!” another one said “yes, if we are not sure about anything we see the manager and she will update us or try to make arrangements for us (to be updated)”. The manager gave examples of how other health care professionals had provided staff with training. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and in the interests of service users. Financial procedures are followed and staff receive regular supervision and appraisals. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The current manager has been registered since July 2005. Prior to this the manager had experience in managing a day centre and deputy manager experience in a residential home. The manager has the Registered Managers Award and has almost completed the National Vocational Qualification Level Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 23 four in Care. The manager attends local Collaborative Care meetings and Primary Care Trust meetings, which helps to develop her professional links and keep her knowledge up to date. Staff were complimentary about the manager and comments included “I think she is good at her job, professional. You can go to her and she keeps confidentiality” and “She is pretty good. She sorts problems out. Very good with resident problems.” Comments from other health care professionals included “The manager always keeps me informed of any issues or changes” and “A well run care home with very friendly and helpful staff.” The manager uses an externally purchased Quality Assurance System and a package of in house audit tools that are based on the National Minimum Standards. The manager has also prepared a programme of when these audits take place. Results of these audits were seen. Resident meetings are also held and minutes were taken. Resident and Stakeholder surveys were completed during January 2006. The procedure for accounting for service user finances was audited and found to be consistent. Staff supervision sessions are structured and programmed through the year. The home has a system whereby deputies are responsible for supervising staff in their own units and the manager completes all staff appraisals. Records were seen and staff confirmed that regular supervision takes place. The manager provided dates of when maintenance and equipment checks had taken place and a number of these were checked further. All recommendations made by the Environmental Health Officer and Fire Officer had been carried out. The manager has also been proactive in completing a Fire Risk Assessment and Evacuation Plan in line with new Fire Regulations. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Acorn Grange DS0000007611.V320887.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. 1 Standard OP26 Regulation 16 (1) (k) Requirement The registered person must keep the care home free from offensive odours. In particular, actions should be taken to eliminate the risk of odours in the first floor room, as discussed with the manager. Timescale for action 28/02/07 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 3 Refer to Standard OP1 OP2 OP15 Good Practice Recommendations The presentation of the Service Users Guide could be improved to take account of those service users who have a visual or cognitive impairment. The service users contract should be regularly reviewed taking into account the Office for Fair Trading’s recommendations. Improvements could be made to the overall dining experience for general residential service users. In particular, considering alternative solutions that would prevent the ‘queuing up’ system that tends to take up a lot of time during the day. DS0000007611.V320887.R01.S.doc Version 5.2 Page 26 Acorn Grange 4 5 OP18 OP36 The registered person should obtain a copy of the updated Local Inter-agency Adult Protection Procedures available from the Local Authority or from the Internet. Supervision records should be signed by both the supervisor and supervisee to confirm that they are an accurate record of what took place. Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Acorn Grange DS0000007611.V320887.R01.S.doc Version 5.2 Page 28 - 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. 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