Inspection on 22/11/06 for Acorn House

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 House 20/11/08

Acorn House 14/02/06

Acorn House 11/08/05

Acorn House 05/11/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Acorn House 2 Eastbourne Terrace Westward Ho! Bideford Devon EX39 1HG Lead Inspector Adele Adams Unannounced Inspection 22nd November 2006 09:45 Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn House Address 2 Eastbourne Terrace Westward Ho! Bideford Devon EX39 1HG 01237 420777 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) arkcarehomes@hotmail.co.uk Ark Care Homes Ltd Mr Robert James Lewington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Room 6 must not be used to accommodate a service user until:1. En-suite facilities are fully fitted in the identified adjacent room 2. Certified by Building Control department 3. Approved by the Fire Authority 4. National Minimum Standards are met The home is to be registered to accommodate 6 service users who have a learning disability and are within the age range of 18-65 years. 14th February 2006 2. Date of last inspection Brief Description of the Service: Acorn House is registered to accommodate 6 residents who have a learning disability and are within the age range of 18 - 65 years. The home comprises of a three storey terraced double fronted property situated in the seaside village of Westward Ho! The house is in a single terrace of houses situated on a quiet road (access only) to the front. Direct access is provided at one end of the road onto Northam burrows. At the other end, the road joins with another, which provides a level walk to the beach and village amenities. The house has a pleasant private garden to the front and an enclosed secure courtyard to the rear. The home has it’s own transport for residents and residents can also use local transport services. The current inspection report is displayed on the notice board in the staff office – all people in the home have access to this room, the inspection report can also be made available to prospective residents upon request. On the day of the unannounced inspection the provider advised that the residents fees for the home range from £ 1,795 to £ 2,516.25. In addition to the fees, residents also pay for chiropody, some activities – such as a privately run day centre, for toiletries and magazines and newspapers. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced “Key Standards “ to be inspected. Therefore, unless it is felt necessary by the inspector, some other standards will not be inspected. This inspection was an unannounced inspection focusing upon the key standards and took place between 09:45 and 16:45, lasting seven hours. Acorn House is registered as a care home for six residents with a learning disability. The home has a motivated Registered Manager who previously worked at the home and has been in this post for approximately six months. During the inspection, the inspector spent time speaking with and observing 4 residents, spent time speaking to care staff and the manager of the home. A tour of the home was also made, during which all rooms and accommodation were viewed and time was also spent reading documentation, including; case tracking residents’ records, reading the home’s health and safety records, quality assurance records and policies and procedures. The service provided a completed pre inspection questionnaire and three completed residents surveys before the on site inspection began. These provided additional useful information that has been included in this report. What the service does well: This inspection found that the environment is homely and that each of the residents at Acorn House has their own spacious, comfortable and wellfurnished room, each room shows the different likes and interests of each resident. People wishing to move to Acorn House have their needs assessed before visiting the home, they can then visit the residents and staff before a decision is made whether or not the home will provide the right environment for them to live in. Each resident has their needs recorded clearly resulting in the residents needs being met with good support and guidance from the staff. The level of staffing at the home is good which enables staff to meet residents needs well. Each resident has a key worker who has the most involvement with the resident, this system works well - residents indicated their awareness of who their key workers are and communicated well with them. Residents are enabled to access health care services outside the home with the support of the staff. A well balanced diet is enjoyed by the residents and they are able to be involved with the shopping and kitchen activities if they wish, which adds to Acorn House being seen as their home. The residents are able to access the local and surrounding community which results in the residents enjoying interesting days including trips out, day outings and holidays. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 6 The staff at Acorn Manor continue to enjoy their work and continue to feel that they are able to provide choice and opportunities for residents and enjoy the positive atmosphere at the home. Acorn House has an enthusiastic Registered Manager who is working hard to meet the National Minimum Standards. What has improved since the last inspection? What they could do better: This inspection has identified that improvements can be made in the following areas: Residents’ pre admission assessments should be available in the home as they provide useful information for staff and enable resident records to be fully inspected to demonstrate that the admission procedure is followed correctly for all residents at Acorn House. Staff records should be available in the home as these may be needed by the registered manager and would also allow a thorough inspection to show whether or not all the correct checks are undertaken before someone is employed to work at the home. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 7 Homely remedies are sometimes used in the home for residents such as cold remedies; these should be listed in the medication guidance after agreement with the doctor and a pharmacist. This is so that staff have direct access to this information and be confident with the action they take and that they have delivered care safely. Essential staff training has lapsed slightly, this could be improved by having a staff training plan in place which will inform which staff need to update their training and when the training is needed. Quality Assurance and quality monitoring can be further improved by introducing an annual development plan this can be used in several ways, one of which is to show how survey findings have been acted upon by the service. 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 House DS0000060241.V315285.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive sufficient information to help them decide whether Acorn House is the right place for them to live. Residents are thoroughly assessed before admission to ensure staff can meet their needs. EVIDENCE: The four residents living at Acorn House were spoken with but it was not possible to discuss this standard in depth with them. Therefore, two residents’ records were read and followed to see what information is gathered before a resident is admitted to the home. The pre admission assessment for one of the residents was not held at the home but at the company head office. All resident records should be held on site. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 10 The registered manager advised that the pre admission information consists of an assessment that is undertaken by the staff /care manager at the residents’ previous care home. The potential resident and their care manager are also met by the provider and the manager of another home within the company. If assessed as appropriate by all involved in the assessment process the potential resident is able to visit and spend time at the home. Evidence of this was seen in one of the two residents records that were case tracked. The registered manager of Acorn House does not currently get fully involved in the pre admission assessment process. Relatives were not in attendance at this unannounced inspection, therefore their views could not be obtained. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key inspection standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents at Acorn House each have a good regularly reviewed individual care assessment and plan of how their assessed needs will be met, this includes good and appropriate risk assessment. EVIDENCE: Residents and staff were spoken with and observed; during this time the residents were enabled and supported by staff to make safe and appropriate decisions – for example, residents and staff were observed organising their day which included making decisions about where they were going, what was appropriate to wear, and where they would eat their lunch. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 12 Two of the residents care plans and risk assessments were read and these gave clear information about each residents needs and how these should be met. The residents’ risk assessments are now clearly linked to the residents care plans. A member of staff said that all staff are involved in writing the residents risk assessments and that a risk assessment update has been arranged for staff. The process and writing of risk assessment was discussed with the Registered Manager and further examples of risk assessment were read and discussed. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 12,13,15,16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents at Acorn House receive a well-balanced nutritious diet and are fully supported to participate in daily life and daily activities within the home, make use of local facilities outside the home, and go on regular trips and outings. EVIDENCE: The inspector spoke with and observed residents and read records and case tracked x 2 residents records in respect of: Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 14 Meals and mealtimes – these are very flexible, special dietary provisions are made with good results, there is access to snacks and drinks and the dining environment. The lunchtime meal was observed and the atmosphere was relaxed and staff and residents ate together and enjoyed the food. All of the residents told the inspector they enjoy the food at Acorn House. Residents’ records x2 were case tracked to find out what records are made and kept about residents’ diets and whether or not they have any special dietary needs. The records showed that both the attention to and the recording of the residents diet and weight related health and care needs are very good and that there has been a health benefit as a result of this. The home keeps a record of the food served and this was seen. Fresh fruit and vegetables are available and that other foodstuffs / products in the home are of good quality. Health and safety monitoring records were read – such as fridge temperatures – cleaning rotas (night staff only follow a rota) showing due diligence with regard to food safety. The inspector observed areas in the kitchen and found that the kitchen was clean and has appropriate storage facilities, a fire extinguisher and fire blanket are available in the kitchen, the First Aid box available in staff room. Staff and residents were spoken with about the activities that are available both inside and outside the home and this showed that a wide variety of trips, outings are undertaken and that these are usually on a one to one basis. Two residents’ records were case tracked and these contained details of their individual wishes – likes /dislikes, the contact residents have with their family and friends and the visits and outings that they go on. Photographs showing some of the outings that have taken place were on display in both the residents’ rooms and in the lounges and staff room. One resident talked briefly about a holiday they had been on – there were also photographs of this on display. All residents’ rooms were seen during the inspection; the rooms are furnished in a homely manner, showing each resident’s individuality, the residents spoken with like their rooms. Three residents surveys were read, one resident has expressed a desire to live in a different environment and records were seen that show that the manager and provider are working with the resident in attempt to assist them in achieving this goal. The resident also talked about this with the inspector and the Registered Manager during the inspection. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Acorn House have their care needs are met in an individualised and personal manner. EVIDENCE: Two residents’ care records were inspected, these clearly showed each resident’s personal care needs, physical and emotional needs and medication needs – evidence of healthcare needs being met were also seen during case tracking and included: a resident attending a dentist, and the involvement of other healthcare professionals including; the continence nurse specialist, a consultant psychiatrist, a Community Psychiatric nurse, a General Practitioner and a District Nurse. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 16 The inspector spoke with staff and residents about their personal care needs, this showed that residents are satisfied with the way in which their care needs are met. The residents’ records were read and residents and staff were observed this enabled the inspector to see that staff communicate skilfully and respectfully with the residents about their physical, emotional and medication needs and residents responded well to the staff. The inspector looked at what medicines has been given in the last 3 months on an ‘as required’ basis and found everything to be recorded appropriately. Up to date medication guidance and policies are available in the home and were read by the inspector, these had been recently reviewed and now include reference to resident’s being able to self medicate if this is assessed as appropriate – the homely remedy section of the policy was missing and this is to be addressed by the Registered Manager. The residents Medication administration records were read by the inspector – these highlighted that the recoding of medication given by staff needs to be improved as there was a gap in the medication record where the record had not been signed and the handwriting of prescriptions needs to be improved – a handwritten record had not been signed by a doctor. Medication storage facilities were inspected and were found to be satisfactory. The last pharmacist inspection was read – this was done on 2/02/06 and was satisfactory. A member of staff told the inspector they had undertaken a medication course and the registered manager confirmed the information contained in the Pre Inspection Questionnaire that the supplying chemist to the home had provided additional medication training to the home. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaint procedure in place at Acorn House and residents are protected from abuse by knowledgeable staff. EVIDENCE: A resident was spoken with about what they would do and who they would go to if they were unhappy about something, the resident was able to help the inspector understand that they felt able to approach any of the staff but would probably go to their key worker or the registered manager. A discussion with the registered manager took place, he confirmed there have been no changes in relation to the way in which complaints and the protection of vulnerable adults is managed in the home. The registered manager also advised that he had recently introduced in house training and so far this included an update about Adult Protection. A member of staff was spoken with and confirmed they had recently received an in house adult protection update. They said the session had been useful and also said that they were aware of the complaints procedure and process and described who they would contact and what action they would take if a complaint were made. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 18 The policy and procedure for the protection of vulnerable adults was read, which is based upon the Local Authority’s Alerter’s Guide. Both this and the complaints policy / process were seen by the inspector and had been reviewed on 2/8/06 and approved on 11/10/06. The Local Authority guidance – The Alerters guide is available in the staff room for reference. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Acorn House provides the residents with a clean, homely and comfortable home to live in. EVIDENCE: Each of the residents was spoken with about the accommodation at Acorn House. Each resident gave permission for the inspector to visit each of their rooms. Each room was found to be large, light, well furnished in a homely style and individualised by each resident, two resident bedrooms felt particularly cold – one of the residents prefers their room to be cold and the registered Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 20 manager was to investigate why the other room was cold –all other areas of the home were heated at a comfortable temperature. One resident showed the inspector their room and told the inspector that they like living at Acorn House. The inspector toured the home – viewing all other rooms/areas in the home – all were found clean, tidy and homely. The Registered manager is booked to attend an infection control study day on 11/12/06 and plans to cascade the information at an in house training session. The member of staff spoken with had not undertaken any infection control training or education whilst employed at this home but was aware that the Registered manager is booked to attend training and plans to update the staff following this. The registered manager told the inspector that there has not been an environmental health inspection of the home since it was registered two years ago. The inspector was advised in the pre inspection questionnaire that some remedial decorating had taken place and that carpets in some areas have been renewed – this was seen during the tour of the home. A new replacement suite has been provided for the lounge and the home has a new vehicle. These were seen during the viewing of the home. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 32, 34 and 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents at Acorn House are cared for by appropriate numbers of staff who understand their own and others responsibilities at work, however essential staff training such as moving and handling and food hygiene has lapsed and staff records were not accessible as they are not held on site. EVIDENCE: Staff records in relation to staff training and the home’s recruitment processes could not be inspected, as staff records are currently not held on the premises. A member of staff was spoken with about the recruitment process at Acorn House, which indicated that the correct recruitment process and checks are followed and undertaken. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 22 The registered manager advised that staff are either working towards or have gained NVQ level 2 and 3 qualifications in care – this was confirmed by staff that were spoken with. A member of staff was spoken with about the training provision for staff working at Acorn Manor. They confirmed what the registered manager had also stated – that is, staff are currently working towards NVQ level 2, 3 and 4 and that 50 of staff have an NVQ Level 2 qualification or above. One member of staff has a Diploma in Health and Social Welfare. The registered manager advised that in house training had begun and so far had included the role of the support worker and adult protection; a member of staff also independently confirmed this. Evidence was seen that shows that training has been arranged in the following areas; Infection Control – 11/12/06; First Aid training 18/12/06; Food Hygiene training – 8/2/07 and physical intervention training is arranged to take place 07/02/07. A session about the writing of risk assessments is planned for staff – 3/01/07. The registered manager advised that staff do not have an individual training plan and that staff training is being developed. The staffing rota was read and this showed that appropriate levels of staff are on duty at the home, staff also confirmed this. The registered manager advised that all residents receive individualised care from a dedicated member of staff between the hours of 8am and 8pm. On the day of inspection, there were 5 members of staff on duty plus the registered manager. At night there is one member of staff on duty with the back up of an additional member of staff sleeping in. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection 23/11/06. The homes performance was assessed against key standards 37 and 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Acorn House is well run by staff that always put residents first, who communicate well with visitors to the home and the Commission for Social Care Inspection. EVIDENCE: The inspector spoke with staff, read residents records, spoke with the manager of the home, read the pre inspection questionnaire, read three residents surveys, read health and safety monitoring and servicing records and read the homes newly developed and implemented quality assurance audits. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 24 The registered manager advised that he is enjoying the challenge of managing the home and believes the smooth running of the home and good care received by the residents should be attributed to the good staff team that is in place at the home and he is in the process of undertaking the NVQ Level 4 Registered Managers Award. Staff also advised that the home is well run and has a positive staff team who respect the residents and each other. The atmosphere was again comfortable and relaxed throughout the inspection. Quality assurance is in the process of being addressed and there are now clear quality audit trails – the inspector saw evidence of the work done to date, which included an audit of staffing levels and the communication book. Resident satisfaction questionnaires are now undertaken on a quarterly basis, the responses were read by the inspector and honest feedback from residents was seen. Family questionnaires are also undertaken and the findings and feedback from families was excellent. Questionnaires from visiting professionals had been received and again some open responses were received which are being considered and will probably result in some changes being made. The policies and procedures are in the process of being updated, the inspector was provided with evidence of this and saw policies had been reviewed and updated – the registered manager advised that policies and procedures are being updated to ensure that all of policies referred to in the Standards for younger adults are developed and put into place – this was evidenced in an action plan. The pre inspection questionnaire showed that the home takes appropriate and regular health and safety checks within the home, this was confirmed through discussion with the registered manager, discussion with a member of staff, reading of the homes health and safety records which show that regular checks such as; fire checks, drills and evacuations take place, that regular health and safety checks such as; the recording of fridge and freezer temperatures takes place. Visual Health and Safety checks were undertaken when the home was viewed and showed that regulations are adhered to, such as; window openings are restricted, potentially dangerous substances such as cleaning materials are appropriately stored, dangerous implements are safely stored and staff have the equipment they need to safely care for residents. However, the registered manager confirmed that the provision of heath and safety training such as lifting and handling, first aid, infection control and food hygiene had lapsed and need to be addressed – see also Standard 35. Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Acorn House DS0000060241.V315285.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 Good Practice Recommendations New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. Staff records should be accessible for inspection. Staff records should be accessible for inspection. Homely remedies should be included in the home’s medication guidance. The home should have a staff training plan, dedicated budget and a designated person with responsibility for the training and development programme. Essential staff training should not be allowed to lapse. The home should have an annual development plan and make public any findings in relation to quality surveys. Staff should receive regular recognised essential training. DS0000060241.V315285.R01.S.doc Version 5.2 Page 27 2. 3. 4. 5. 6. 7. 8. YA32 YA34 YA20 YA35 YA35 YA39 YA42 Acorn House Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 House DS0000060241.V315285.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!