Inspection on 04/05/06 for Acorn House

This inspection was carried out on 4th May 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 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 06/10/05

Acorn House 16/06/05

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 Key Unannounced Inspection 4th May 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 House DS0000048016.V291908.R01.S.doc Version 5.1 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 House DS0000048016.V291908.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Acorn House Address 63 Hayes Lane Croydon Surrey CR8 5JR 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) 020 8660 3363 Medicrest Ltd Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2005 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 Kenley, 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 DS0000048016.V291908.R01.S.doc Version 5.1 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 unannounced and involved consultation with the acting manager and staff on duty. One of the owners 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 members of staff were spoken to. Care plans of the last 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 will be reviewed during the next inspection as they had only recently been sent out. However comment cards received from service users and their relatives during the course of the last inspection year – 2005-06 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 on an individual basis. Two complaints have been made about the service since the last inspection. One had been made directly to the home and was appropriately responded to while the other is subject to an investigation by the home. Comment is made under the “Complaints and Protection” section – Standards 16 – 18. 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”. Comments from families, relatives reflect that they are always made welcome and are appreciative of the care and service that is provided. They all perceive that staff always has time to spend with the service users and respect 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 DS0000048016.V291908.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? Since the last inspection the directors of the home have appointed a new manager. The previous manager resigned for personal reasons and the new manager has begun to tackle issues that had not been addressed by the previous management team. One of the key issues the new manager has begun to address is team building and staffing. A number of staff including the former Deputy Manager have also left the home and the new manager is appointing staff who are committed to improving the quality of life for those service users at the home. Team building, supervision and staff meetings are being given high priority to ensure effective team work which was clearly lacking under the previous management team. The Inspector was advised that she plans to assess the quality and capability of her senior staff and appointment a deputy manager internally. The appointment of such staff will undoubtedly lead to a sharing of management responsibilities and enable the manager to focus more on developmental issues. The manage has begun to build a more effective staff team whom she described as “stable” Staff were seen to be kind and caring towards the service users. Most of the previous requirements and recommendations had been complied with although some are still outstanding including the requirement that a Quality Assurance system in line with Standard 33 be introduced. In addition some refurbishment and decoration remains outstanding. All staff were participating in training programmes and those that the inspector spoke to were enthusiastic about their roles. Since the appointment of the new manager it was evident that relationships not only with staff but with service user’s families and friends had greatly improved. The manager has begun to address some of the serious concerns made in previous inspection reports which is to be commended. However for the home to move on and develop further change will be necessary for the positive wellbeing of the service users at the home. The new manager has ensured that all staff who are employed at the home now have a CRB check and two references in addition in addition to all documents listed in Schedule Two of the Care Homes Regulations – thus ensuring the welfare and safety of service users. It is to be hoped that the home will not experience any further management changes given there have been three managers in a very short space of time which clearly affects staff and service users alike. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 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 House DS0000048016.V291908.R01.S.doc Version 5.1 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 the following standard(s): 3 Service user’s admitted to the home since the last inspection all had an assessment carried out by the home and/or care manager. There is now a clear system in place for the registered manager to undertake such assessments and/or receive care management assessments. Therefore the care plan, which is drawn up with information from the assessment, contains 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: A requirement was made at the last inspection that ‘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’ The inspector noted that the last two service users admitted to the home had such Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 10 assessment. There is a clear procedure now in place for such assessments to take place. The assessment inspected contained all the information required as set out in Standard 3. Such 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. By ensuring such assessments are undertaken the home is ensuring that it can meet the needs and manage the service users. The manager must ensure that know service 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 DS0000048016.V291908.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 Service users admitted to the home have their health care needs assessed prior to admission. By ensuring that this assessment is in place along with the care management assessment an appropriate care plan can be developed. In addition by having all this information available the home ensures it can meet the health needs of service users. Further any risks to service users are minimised and carefully managed. EVIDENCE: As outlined in Standard 3 the last two service users admitted to the home had a care management assessment or the home had carried out its own assessment. This assessment now includes health and is used to generate the service user plan. As health needs have know been properly assessed than any risk to service users can be appropriately managed. Service users care plans that were inspected 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. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 12 Since the last inspection there had been several falls. One service user fell out of bed on Thursday, 2nd March and this was clearly and accurately recorded in the accident book. The same service user was found in bed with a broken shoulder on Sunday morning, 5th March. While the service user was taken to hospital and the home could not and have not offered an account of how these injuries occurred. The commission were subsequently informed and the home has yet to complete its own investigation of how this incident occurred – see complaints and protection. There were no service users with pressure sores at the time of the inspection. Staff were seen interacting 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 20th January 2006 and all requirements from the visit have been complied with. All MAR sheets inspected were found to be correct and a returns book was evidenced duly signed by the pharmacist. The manager has introduced a front sheet showing the names and signatures of staff that are authorised to give medication. In addition all service users that take medication have a “medication profile” It is strongly suggested that medication is monitored and included in the monthly report undertaken by the responsible individual to ensure the continuation of good practise. All staff who administer medication have received appropriate training. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 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 the following 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 from last years inspection cycle showed that visitors are always made to feel welcome in the home and the inspector talked to a number of staff, service users, relatives and social workers. 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 comment was received during 2005 and much of the home Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 14 has now been decorated and new furniture has been purchased. Notwithstanding the chairs in the lounge need replacing. 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. Service users have a choice of meals and vegetarians are catered for. The home also caters for those that are diabetic and those that require puree meals as confirmed by the chef. 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 DS0000048016.V291908.R01.S.doc Version 5.1 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 the following standard(s): 16 and 18. Residents in the home and their relatives must be confident that complaints would always be treated seriously and acted upon promptly. The staff within the home must be 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. Failure to ensure such procedures are followed or lack of training can lead to serious concerns and allegations of abuse. EVIDENCE: The complaints record was checked and there had been one entry since the last inspection. This complaint was appropriately managed and responded to by the manager. 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 reviewed stated that they had never needed to make a complaint but were aware of the procedure to be followed should they need too. Of significance is the incident outlined in the “Health and Personal Care” section of this report. Given this incident could not be explained it should have been reported to the local authority for a decision to be made regarding the possibility of an external investigation. While the management of the home have acknowledged this shortfall it is essential that any future incidents or complaints are managed effectively and appropriately. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 16 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. While the majority of staff have undertaken Adult Abuse Awareness training there is a clear need for this to be updated on a regular basis. In the light of the serious incident stated in this report the management of the home have arranged for such training to take place on 13th May 2006. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 19, 20, 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 prior to the last announced inspection “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 inspector noted that both the lounge and library had been redecorated and that new carpets had been laid. One of the directors advised that new chairs were on order for the lounge. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 18 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 safety officer on 25th August 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 bedrooms for those service users who are incontinent. There is one sluice in the home, which is kept locked. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. There are sufficient staff on duty that collectively has the skills and experience to provide a good level of care for the service users in this home. Recruitment procedures at this home are robust which helps to ensure the health, safety and welfare of service users The home does not have as a minimum 50 of care staff qualified to NVQ level 2. This lack of training could lead to staff not having the appropriate skills or expertise to carry out their role within the home. EVIDENCE: Staff turnover in the home has been relatively high. This can be accounted for by the new manager having clear expectations of the standards she expects for the home and by ensuring that all staff are working in a professional manner. There is now a good balance of staff. The manager is supported by three experienced senior staff while there are an enthusiastic team of carers. As stated earlier in this report there is a need to appointment a full-time deputy manager to support the manager in her day to day management of the home. In addition the home has the support of a former manager of the home at weekends who is very experienced and qualified in her own right. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 20 Some of the staff have gained an NVQ level 2 qualification while some are planning to complete NVQ level 3. There is a need to ensure that the home has as a minimum of 50 qualified staff to NVQ level 2. The home will need to submit an “Action Plan” to the commission to advise of how it intends to achieve this standard within an agreed timescale. One of the reasons stated for not meeting this standard was that staff had to pay for the cost of NVQ training. While it does not come within the remit of the commission has to who pays for such training it is suggested that it would most certainly increase the moral of staff if the home contributed to the cost of such training. In addition some staff commented that the cost of such training was too high for them to afford to undertake such training. The staff files of the 3 carers who have been employed since the last inspection were seen and all complied with Schedule 2 of the Care Home Regulations. 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. Recent training has included Dementia, Nutrition and Medication. Copies of induction programmes were seen on staff files. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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 every two months 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 advised this would be completed shortly. The manager advised that she will be seeking Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 22 stakeholder’s views by means of surveys. In addition she will be undertaking an annual audit in line with standard 33. Records of Supervision were available for inspection and take place in line with the standard, although the manager herself as not had any formal supervision since commencing her post. The manager advised that annual appraisals would be taking part during the later part of 2006. 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 although the certificate of public liability certificate had expired at the time of the inspection. Kitchen practices were good and all staff have received appropriate health and safety training. Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 23 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 X X 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 2 X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 3 2 X 1 Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES. 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 OP14 Regulation 17 Requirement The registered person must ensure they obtain guidance on the Data Protection Act 1998. (Not met by 30/11/05) The responsible individual must ensure all allegations and incidents of abuse are followed up promptly and action taken is recorded. 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. (Not met by 301105) The registered person must ensure that furniture in communal rooms is in a good state of repair. Broken or worn furniture must be replaced or repaired to a satisfactory standard. The responsible individual must send an “Action Plan” to the commission advising of how the home is to achieve a minimum of 50 qualified staff at NVQ level 2 or above. DS0000048016.V291908.R01.S.doc Timescale for action 31/08/06 2. OP18 13 04/05/06 3. OP19 23 31/08/06 4. OP20 23 31/08/06 5. OP28 18 30/06/06 Acorn House Version 5.1 Page 25 6. OP33 24 7. OP33 26 8. OP34 25 9. OP34 25 10. OP36 18 11. OP38 13 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 And The registered person must ensure that an internal audit of the home is undertaken at least one each year. (Not met by 30/11/05) The responsible individual must ensure monthly visits are made to the home and a written report, which must be sent to the commission is made of the visit. The responsible individual must ensure that the home has appropriate public liability insurance and that the certificate is available for inspection. The responsible individual must send to the commission the homes business and financial plan for 2006-07. The responsible individual must ensure that the manager receives supervision as laid down in Standard 36. The responsible individual must ensure all accidents, injuries and incidents of illness or communicable discease are recorded and reported. 31/08/06 31/05/06 31/05/06 30/06/06 31/05/06 04/05/06 Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Acorn House DS0000048016.V291908.R01.S.doc Version 5.1 Page 27 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 DS0000048016.V291908.R01.S.doc Version 5.1 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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