Inspection on 16/06/05 for Acorn House

This inspection was carried out on 16th June 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

Acorn House 02/12/08

Acorn House 08/01/08

Acorn House 22/01/07

Acorn House 04/05/06

Acorn House 06/10/05

Acorn House 25/11/04

Acorn House 04/05/04

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

CARE HOMES FOR OLDER PEOPLE Acorn House 63 Hayes Lane Croydon Surrey CR8 5JR Lead Inspector Michael Stapley Announced 16 June 2005 09:30 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 House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Acorn House Address 63 Hayes Lane Croydon Surrey CR8 5JR 020 8660 3363 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) Medicrest Ltd Rebecca Francis Spratt Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2004 Brief Description of the Service: Acorn House is a 31-bed home caring for elderly people who are suffering from some form of dementia. It is linked to Acorn Lodge (a similar care home owned by the same company), and the two share a large rear garden. The home is situated in the pleasant rural area of Kenly, the only drawback being that it is some distance from the nearest public transport links. The home’s stated aims and Objectives are to ‘provide a home from home’ a friendly atmosphere where staff are approachable and an open relationship is encouraged between residents, staff and relatives to ensure a happy home and ensure the well being of the residents. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first statutory inspection during the year 2005/2006. The inspection was announced and involved consultation with the registered manager and staff on duty. One of the directors of the home was also present for feedback and evaluation at the end of the inspection process. The inspection took place over one day and during that time a tour of the premises was undertaken, several service users and key members of staff were spoken to. Care plans of three service users, who had been admitted since the last inspection, were examined as well as various records required for the health and safety and wellbeing of both the service users and staff. Comment cards that are routinely sent out by the Commission for Social Care Inspection prior to the inspection were received from ten service users and nine of their relatives and were all very positive about the care and services provided. Most of the service users suffer from dementia however several were spoken to during the course of the visit and two members of staff were spoken to privately on an individual basis. A number of relatives were also spoken to during the course of the inspection. Most of the comments were favourable although there was some concern regarding the timescales for refurbishment and decoration. No complaints have been made about the service since the last inspection either to the home or directly to the Commission for Social Care Inspection. What the service does well: This home provides a safe and comfortable environment for service users, the majority who have some form of dementia. Although communication can be difficult with them one commented that he “felt very happy here “and another that the” food was very good”. Relative’s pre-inspection questionnaire replies reflect that they are always made welcome and they are appreciative of the care and service that is provided. They all perceived that staff always had time to spend with the service users and respected their individuality. The daughter of one service user commented to the inspector on how much her mothers’ quality of life had improved since she moved into the home. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 6 Staff come from a wide range of nationalities however their language skills are good and pose no problems. On the day of this inspection they were seen enjoying the musical entertainment with service users. What has improved since the last inspection? What they could do better: This is the homes first inspection since the manager was confirmed in post by CSCI. She has made a positive start in the development of the home. However one of the outstanding requirements is the lack of a quality assurance system and annual development plan. This is a key to ensuring the home is meeting its Statement of Purpose and evaluating its services. The manager advised that relationships with relatives and family friends needed improving. For example it was noted that one relative did not know who the key worker was her mother. The home therefore needs to do some work in this area to improve relationships. Surveys of stakeholders need to be undertaken and assessed in order to improve the quality of service. In addition the manager stated that she did not have a dedicated budget and always had to ask for petty cash. This Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 7 was discussed with one of the directors of the home who agreed to discuss this with the manager. 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 House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Service user’s admitted to the home since the last inspection had not had an assessment carried out by the home. There is no clear system in place for the registered manager to undertake such assessments. Therefore the care plan which is drawn up with information from the assessment does not contain all the necessary information the staff need to satisfactorily meet the needs of the service users. Standard 6 does not apply, as the home does not offer intermediate care. EVIDENCE: Of three service users admitted to the home since the last inspection only one had an assessment undertaken by the registered manager. The one assessment completed was undertaken by a part time member of staff and did not contain all the information required as set out in Standard 3. These assessments are vital as they are used to draw up the care plan and provide the basis of the work carried out by the key worker of the service user. Further by not undertaking such assessment the home may be admitting service users that it can not manage. In addition there was no set procedure for ensuring such assessments take place. The manager must ensure that know service Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 10 users are admitted to the home without such an assessment being undertaken and ensure that whenever possible relatives and family members are involved in the process. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Some residents admitted did not have their health care needs assessed by the home prior to admission. The home must ensure it has all this information in order to complete the care plan. If information is not available or has not been sought it could pose a risk to the service user. In addition the home way not be able to meet the needs of service users. EVIDENCE: As outlined in Standard 3 a number of service user’s had not had an assessment prior to admission. This assessment includes health and is used to generate the service user plan. If health needs have not been properly assessed than there is a potential risk to service users. However a sample of service users care plans was inspected and showed evidence of regular review and in some cases the involvement of relatives. The advanced stages of dementia of many of the service users preclude their involvement. Since the last inspection there had been several minor falls, while none have required admission to hospital all have been clearly and accurately recorded in the accident book. One service user was to hospital on 17th April 2005 and the home had informed the commission in writing. There were no service users with pressure sores at the time of the inspection. Staff were seen interacting Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 12 with service users in a positive manner and were treating them with dignity and respect. Despite care staff coming from a wide range of nationalities they were able to communicate well and effectively with the service users. The last inspection by the pharmacist for the home was on 24th February 2005 and all requirements from the visit have been complied with. However during the course of this inspection a slight error was noted was noted on one service users MAR chart. This was brought to the attention of the manager who immediately rectified the situation. Notwithstanding errors such as these can have extremely serious consequences for the home and staff concerned. The manager must monitor the administration of medication to ensure such errors do not occur. All staff who administer medication have received appropriate training. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, and 15. It can be difficult to communicate with some of the service users in this home, and many of them appear to appreciate a quiet and peaceful life and the pleasant surroundings, which the home provides to enable them to do so. Care staff are encouraged to assist service users to maintain a degree of independence and participate in social activities if they choose. Visitors are encouraged and always made welcome. EVIDENCE: Comment cards showed that visitors are always made to feel welcome in the home and the inspector talked to a number of friends and relatives. Further evidence from comment cards showed their was positive staff interaction with service users. One comment card stated “we have always been made welcome in the home and are particularly grateful that we can bring our dog with us on visits as this gives our friend great pleasure (and some of the other residents). We appreciate having the monthly newsletter to keep us in touch with events in the home” Another stated that “The care my mother receives is of a high standard and I am pleased with her life there. However I feel that the décor and some of the furniture needs changing urgently, as it is looking quite shabby” The later part of this comment has been addressed elsewhere in this report. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 14 On the day of the inspection, various activities were the order of the day and care staff at the home were actively encouraging service users to participate. The manager of the home is keen to develop activities as she sees them as pivotal in the development of service users at the home. The advanced stages of dementia of many of the service user’s means that they appreciate a degree of routine in their daily lives however staff were seen encouraging them to exercise as much choice as they are able. Lunch was observed at this visit and comments about the food have always been positive. The amount of food actually eaten is duly recorded if there are concerns regarding appetite. In addition the weight of service users is monitored and any adverse concerns are referred to relatives and/or GP. It is suggested that advice be sought from a dietician when service users have lost weight since admission. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 15 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 and 18 Residents in the home and their relatives are confident that complaints would always be treated seriously and acted upon promptly. The staff within the home are aware of and work within the Local Authority guidelines for the protection of vulnerable adults and refer any allegations of abuse under the Croydon Vulnerable Adults Procedure. EVIDENCE: The complaints record was checked and there had been no entries since the last inspection. The complaints book and associated procedure is available in the entrance hall and it is included in the homes statement of purpose. The majority of relatives comment cards stated that they had never needed to make a complaint but were aware of the procedure to be followed should they need too. All of the staff members that were spoken to displayed knowledge of adult abuse procedures and all felt confident that they could approach the home manager with any concerns. There is a need to ensure all staff have undertaken Adult Abuse Awareness training as it was evident that at least seven members of staff have yet to complete this training. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 16 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, 24 and 26 The home is reasonably well maintained with due regard to the health and safety of both staff and service users. It is clean and provides a pleasant place to live with a homely and cheerful atmosphere. EVIDENCE: The home is in a pleasant residential area and is in keeping with surrounding properties. Since the last inspection much of the home has been redecorated and looks much brighter. However there is a need to continue with the programme of redecoration and refurbishment. One relative commented that “Acorn House now needs to be updated by having the lounge and Library room redecorated with new wallpaper; new carpets and chairs for the residents. Also better staff room” The manager and one of the directors advised that this work would be carried out shortly. There is a delightful rear garden that has been well maintained and it accessible to all service users who enjoy it in the summer months. The home had an inspection from the local authority’s food Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 17 safety officer on 17th February 2005 and all requirements from that inspection have been complied with. Service user bedrooms are pleasant and they have been personalised by their occupants. Most of the bedrooms contain all of the furniture and fittings as per standard 24. Where a service user has made a decision not to have a particular item of furniture or if the space is inadequate this is duly recorded. All radiators are covered and windows have been fitted with restrictors. Laundry facilities are small but adequate and the home is generally odour free. Alternative floor covering has been provided in three bedrooms for those service users who are incontinent. There is one sluice in the home, which is kept locked. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 18 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 and 30 There are sufficient staff on duty who collectively have the skills and experience to provide a good level of care for the service users in this home. Robust recruitment procedures and staff training ensure that service users are well cared for. EVIDENCE: Staff turnover in the home is relatively low; many of the staff have been with the home for some years. There is now a good balance of staff. The manager is supported by five experienced senior staff while there are an enthusiastic team of carers. There was some concern about the role of the deputy manager who only works on a very part time basis. While is very experienced and knowledge being the homes former registered manager consideration should be given to appointing a full time deputy manager. Many of them have gained an NVQ level 2 qualification while some are planning to complete NVQ level 3. The staff files of the 3 carers who have been employed since the last inspection were seen and complied with the standard. Copies of their induction programme were seen. No new member of staff is employed until POVA and CRB checks are complete. There is now a very through training programme in place and staff spoken to confirmed that they had been able to access training. Records of Supervision were available for inspection and take place in line with the standard. The manager advised that annual appraisals would be commenced in July 2005. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 19 Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 20 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 and 38 The home benefits from a strong staff team with good leadership, which ensures a high standard of care. Attention to health and safety procedures means that the wellbeing of service users is maintained. EVIDENCE: Meetings are held for service users on a monthly basis and relatives/friends are always welcome to attend. Staff meetings are held every month and minutes of the last three meetings were evidenced. It is suggested that staff sign them to ensure they have read them. The home has not yet developed its quality assurance system or annual development plan although the manager this would be completed shortly. The manager advised that she will be seeking stakeholders views by means of surveys. In addition she will be undertaking an annual audit in line with standard 33. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 21 The home does not take responsibility for the financial affairs of any of the current service users. Maintenance records were seen and were all in good order. Fire safety requirements had all been complied with. The home has the appropriate insurance policies in place. Kitchen practices were good and all staff have received appropriate health and safety training. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 22 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x x 3 Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 23 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. 2. Standard OP14 OP3 Regulation 17(1) 14 Requirement The registered person must ensure they obtain guidance on the Data Protection Act 1998. The registered person must ensure that care management assessments are in place prior to admission and where service users are self funding a care needs assessment is in place. Placement and assessment procedures must be reviewed Action as per no 2 above The registered person must make suitable arrangements for all staff to undertake adult abuse awareness training. The registered person must draw up and send to the CSCI, local office an ongoing maintenance and development programme regarding the renewal of the fabric and decoration of the home The registered person must ensure that the visitor’s room is appropriately decorated and refurbished for the use of service users to meet their friends and relatives without further delay The registered person must ensure all communal areas are Timescale for action 30/09/05 30/09/05 3. 4. OP7 OP18 14 13(6) 30/09/05 30/09/05 5. OP19 23 30/09/05 6. OP16 20 30/09/05 7. OP20 23 30/09/05 Page 24 Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 decorated as a matter of priority. 8. 9. OP20 OP22 23 23 The registered person must replace the floor coverings in all communal areas. The registered person must ensure that the ‘pink’ top floor bathroom is redecorated without further delay. The registered person must ensure that furniture in service user’s bedrooms is in a good state of repair. Broken or worn furniture must be replaced or repaired to a satisfactory standard. The registered persons must replace/renew the sink and cupboards in the laundry room as a matter of priority. A quality audit system, including an annual development plan must be in place to assess whether the aims and objectives of the home have been met and:The home must implement a professionally recognised quality assurance or ‘join up’ their own quality assurance tools into a cyclic quality assurance system. The registered person must review the content of the monthly reports it submits to CSCI. This report must be of a far more comprehensive nature. It should include the monitoring of care plans, health plans and assessment of service users needs. A copy of each report must be sent to the CSCI (local) office. 30/09/05 30/09/05 10. OP24 23 30/09/05 11. OP26 16 30/09/05 12. OP33 24 30/09/05 13. OP37 26 30/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 25 No. 1. Refer to Standard OP38 Good Practice Recommendations It is strongly recommended that the registered provider ensures that at least one member of staff attends Display Screen Awareness Training to ensure compliance with this Standard It is strongly recommended that the registered provider ensures that the Health and Safety representative attend an approved course to ensure compliance with Standard 38.4 2. OP38 Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon 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 Acorn House G53-G53 S48016 AcornHouse V211778 160605 Stage 0.doc Version 1.30 Page 27 - 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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