Inspection on 11/04/07 for Acorn House Care Centre

This inspection was carried out on 11th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Care Centre 25/01/06

Acorn House Care Centre 13/09/05

Acorn House Care Centre 08/03/05

Acorn House Care Centre 24/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Acorn House Care Centre Whalley New Road Roe Lee Blackburn Lancashire BB1 9SP Lead Inspector Mrs Jennifer M Turner Key Unannounced Inspection 10:45 11 and 12th April 2007 th 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 Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn House Care Centre Address Whalley New Road Roe Lee Blackburn Lancashire BB1 9SP 01254 679395 01254 677686 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) Southern Cross Healthcare Mrs Carol Waddecar Care Home 32 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (22) of places Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 32 service users to include: Up to 22 service users in the category of OP - old age (aged over 65 years of age), not falling into any other category. Up to 10 service users in the category of DE (Dementia under 65 years of age) or DE(E) (Dementia over 65 years of age). Dementia care to be provided in the designated dementia unit and bedrooms numbered 21,22,23,26,27,28,29,30,31, and 32. The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 25th January 2006 2. 3. Date of last inspection Brief Description of the Service: Southern Healthcare Ltd own Acorn House Care Centre. Mrs Carol Waddecar is the manager, although she is not yet registered, and is responsible for the day-to-day management of the home. The home is registered to offer accommodation and personal care for twenty-two older people, and ten older people with dementia. The home is located in a busy community on the edge of Blackburn. It is on a main road with access to shops, a church and other community facilities. Bus services are nearby. The front of the home looks onto the shops and road and at the rear there are views of the garden and patio. Car parking facilities are at the rear. The home is a purpose built twostorey building with accommodation in two parts. The dementia unit is on the first floor. There are lounge and dining areas for each unit. There are bathroom and communal toilet facilities on each floor. Every resident in the home has a single bedroom, with an en suite toilet and wash hand basin. Bedroom doors are lockable. There is a passenger lift to the first floor area. The weekly charges at the home vary according to the assessed care and range between £354 for Local Authority funded people to £385.50p for people living in the dementia unit. (i.e. £375 plus £10.50p top up fee). Privately funded people are charged £445 with additional charges being made for hairdressing, personal newspapers/periodicals, additional toiletries and Aromatherapy. The home is on the preferred providers list for Blackburn with Darwen Borough Council. Information about Acorn House can be obtained from the home in the form of The Statement of Purpose and Service Users Guide. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, including a visit to the home, took place on the 11th and 12th April 2007 and lasted 11 hours. Wherever possible the views of residents were obtained about their life at the home. Due to memory and communication difficulties, some of the residents were unable to engage in conversation or make comment about their experience of living in the home. Detailed notes were taken, which have been retained as evidence of the inspection findings. At the time of the inspection the occupancy level was twenty-eight. There were nineteen people in the residential unit and nine people in the dementia unit. On the first day the manager, senior care staff, care staff, ancillary staff (chef, kitchen assistant, laundry person, housekeeper and domestic staff) and people in the residential unit were spoken with. The Operational Director, the administrator and people in the dementia unit were spoken with during the second day of the inspection. During the course of the inspection, procedures and records were also examined, lunch was taken with the residents, activities were observed and the premises were viewed. Information from a pre inspection questionnaire and two comment cards from residents and relatives, contributed toward the findings. Areas that needed to improve from the previous inspection were looked at for progress made. The home was assessed against the National Minimum Standards for Older People. What the service does well: Prior to people moving into the home, their needs were assessed. They were consulted about the level and type of care they required and could visit the home to look for themselves at the facilities offered. Important information needed to support them in every day living was recorded and used to plan the care they required. This helped to personalise care and show staff what they should do to achieve this. All people spoken with said contracts were given to them. This informed them of the terms and conditions of residence. Staff training was continuous and a number of care staff continued to study for their National Vocational Qualification level 2. This training helps them to understand the diversity of residents needs. Healthcare needs were also monitored and staff worked with visiting medical professionals for the benefit of the residents. People stated that they “always Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 6 received the medical support needed” and that “Doctors are always called when required”. Relatives who sent written comments for the inspection said they were made welcome at the home and could make a visit in private if they wished. They also said they were always kept informed of any changes in their relatives care needs. Social activities were managed well even though the post of “Activities Organiser” was vacant. Community contact was also maintained – “I go to the local pub over the road”. There were no rules in the home and routine was personal to each resident. People said their meals were ‘good’ and “well varied” with choices offered, and “we get home cooked meals”. Complaints were taken seriously and residents and relatives had confidence that any issue they raised would be dealt with properly. Residents said they were comfortable and warm. They considered staff to be “polite, always there for them and respected them”. Recruitment and selection of staff was thorough and protected residents. The level of staffing maintained, training provided and supervision was good which meant members of a competent, diverse, qualified staff team cared for residents. Residents and staff benefited from regular meetings and were informed of any changes planned. The home was organised and managed efficiently. What has improved since the last inspection? The medication policy and procedures have been reviewed against the professional guidelines of the Royal Pharmaceutical Society. This ensures that there is continuing compliance and that medicines are administered safely. The recruitment of staff includes obtaining references from a previous employer. This ensures that the manager receives information as “up to date as possible” to assist in the decision whether to employ someone or not. Risk assessments are reviewed to ensure that the level of care can be increased if required. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 7 The actions and equipment needed for all aspects of moving and handling are specified in the care plan. This ensures that staff are appropriately trained and the correct equipment is available to meet the diverse needs of people being cared for. Residents are assessed and allocated their own continence aids. This helps to give a true picture of a persons healthcare needs. Details of meals taken by residents are dated. This ensures that there is a correct record of what people have eaten. 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. The summary of this inspection report can be made available in other formats on request. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3:6 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. A comprehensive assessment procedure was carried out prior to people moving into the home. This meant that their diverse needs were known and met. EVIDENCE: Four residents were case tracked. One was the most recent admission to the home. Assessments from social workers and health service personnel were evident on files examined. A member of the management team made a pre admission visit to prospective residents. This visit took place, either in the person’s own home or in hospital. People confirmed being visited. Copies of these assessments were viewed on the files examined. Records showed that following the assessment, people received a letter confirming that staff at the home could meet their diverse needs. Residents said that they had been given Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 10 a copy of the Statement of Purpose and Service Users Guide, and these showed the fees. Copies were seen in residents’ bedrooms. Any risk assessments required were completed. People spoken with said either they or a member of their family had visited the home prior to a decision being taken about residency. There was evidence on files that contracts had been drawn up and the manager and the resident/relative concerned signed these. Staff said they were informed of the needs of people admitted into the home at “change over meetings”. The home does not offer Intermediate Care. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7;8;9;10 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Healthcare needs were identified and met the diverse needs of people in the home. Personal care was delivered in a way that promoted people’s privacy and dignity. EVIDENCE: The content of care plans had improved and further modifications were being addressed. However, one of the plans for a person staying in the home for a period of short stay, did not identify in detail, how elements of care were to be provided by the staff. Four other people’s case files were examined and they held the appropriate information and risk assessments. Daily diary sheets were completed and care plans and risk assessments were reviewed on a monthly basis. Members of the care staff and residents spoken with confirmed their involvement with reviews and there was evidence in some care plans that the resident or their relative had signed the documentation showing their involvement. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 12 A diverse range of risk assessments were completed which included the prevention of pressure sores, nutrition, falls and moving and handling needs. Pressure mattresses and cushions were seen to be in use. Personal records on files examined showed that appropriate health care was accessed for residents. Staff confirmed, and records showed, that District Nurses were in attendance if required. People said that they were able to register with a General Practitioner of their own choosing. Records showed that appropriate arrangements were in place to ensure that people had access to specialist medical, nursing, dental and chiropody services according to need. Records showed that hearing and sight tests were arranged for individual people when required. There were policies and procedures for all aspects of medication management and the medication policy complied with the Royal Pharmaceutical Society Guidelines. Medication storage and administrative systems were viewed and staff responsible for the administration of medication were aware of their responsibilities. Individual medication and records were checked and were kept and recorded correctly. The Medical Device Alert relating to Lancing devices was discussed. The home has the relevant information, but District Nurses deal with all injections. On each unit medication was stored in a separate, clean locked room. Records showed that the temperature of these rooms was monitored daily. There were adequate cupboards for the storage of the medications. There was little excess stock kept on either unit and excess medication was returned to the Pharmacist on a regular basis with the appropriate records kept. The Controlled Drugs were stored and recorded properly and the balance checked was correct. Although people were asked if they wished to administer their own medication, records showed that none chose to do so. One person commented, “they give me my medicine when I need it”. People spoken with felt that the care offered by staff was good. “They are good girls and always around to help” and “staff are always available to discuss any needs.” Some comments made by relatives in residents surveys in respect of the staff were that they felt “staff had the right skills to care for their relatives”. People felt that that staff respected their privacy and were “respectful when speaking to me.” Staff confirmed that the areas of privacy and dignity were included during induction training. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12;13;14;15 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Dietary, social, cultural and religious needs were being met. People were able to make choices about their life at the home so that their lifestyle met their preferences. EVIDENCE: The known likes and dislikes of the residents were seen noted in their care plan. Their usual routines e.g. what time they liked to go to bed and get up, were also recorded. Choice was encouraged and the routines at the home were flexible and were ‘resident led’. People spoken to said they were able to make choices about what they did and when they did it. They were able to use their rooms when they wanted to. The manager said that a replacement was being sought for the activities person who had recently resigned. People spoken with said they missed the morning activities although there was a current programme of activities being provided by the staff. Sing a longs and music were popular. One gentleman helped the handyperson with gardening Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 14 activities. The activities that people took part in were seen recorded in their daily notes. From discussion with people, it was obvious that their friends and relatives were made welcome at whatever time. The visiting policy was clearly set out in the Statement of Purpose. Discussion with staff members confirmed their understanding of the policy in respect of upholding the rights of the residents to choose whom they wished to see or not see. People confirmed that they were free to attend activities that took place in the community if they so wished. Information on the notice board gave details of visiting clergy. One gentleman liked to visit the local public house on a weekly basis. The manager said that she intended to extend the contact that people had with the local community. Those people who were able were encouraged to handle their own personal allowance, although records showed that relatives were involved with the payment of fees. Records showed that one relative acted as a “Power of Attorney”. Information relating to advocacy was clearly displayed in the reception area of the home. People said that they had access to their personal records through their involvement with care plans and the review process. One person commented that they were “involved with care plan reviews” and they had the opportunity to “have a say”. Comments made by a relative in a resident’s questionnaire stated that residents meetings gave people the opportunity to “put their views forward” and their requests were acted upon. Menus submitted with the pre inspection questionnaire and those available in the home showed that a balanced diet was being offered. Choices were available at all meals. Staff were seen to ask residents during the afternoon what they wished to have for their tea from food offered. People in the dementia care unit received a supply of both options so that they could make a visual choice at the time of the meal. Alternatives to the menus were also available. Residents spoke highly of the quality of food and said “food was plentiful” and “food was good and well cooked”. The chef said that special diets were provided. Drinks and snacks were seen to be always available. The atmosphere at lunchtime was calm and pleasant. Staff were seen to assist people in a discrete and sensitive manner. People were prompted to eat independently before help was given. The kitchen was clean and tidy. All records were kept relating to food ordering, delivery, storage and cooking. There was a cleaning schedule. Records showed what food options had been taken by residents. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16;18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents were protected from abuse and had access to the homes complaints procedure. EVIDENCE: The complaints policy had been amended and made reference to the Commission for Social Care Inspection and the Local Authority. It was displayed in the hallway, in the Statement of Purpose and the Service Users Guide. People said that they were confident to approach a member of the management team if there were any concerns. A complaints book was available and there had been no complaints since the last inspection. The manager said that any concerns were usually of an internal nature and dealt with quickly and proficiently. A copy of the Department of Health document “No Secrets” was readily available along with the homes “Whistle Blowing” policy. Staff were aware of their responsibilities toward residents. Records showed that eight of the twenty two staff had completed Protection of Vulnerable Adults training. Although relatives administered resident’s finances, records were seen in respect of the handling of resident’s pocket money. Two signatures were made in respect of financial transactions. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is Excellent This judgement has been made using available evidence including a visit to this service. The home was warm, clean and comfortable. A good standard of hygiene was achieved. EVIDENCE: A Fire Risk Assessment was in place and the Fire Procedure was available in the Statement of Purpose. It was observed that the Intumescent strips on bedroom doors had been painted over. The Operational Director sought advice with the Fire Authority during the inspection to ask if these were still fire resistant. She was told that they were, but now new advice is for brushes to be fitted onto doors. Arrangements were then made by the Operational Director for the door fire seals to be upgraded. The fire book showed that regular tests Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 17 of the fire system and fire equipment were made. Records showed that Fire Drills were held every 6 months. The maintenance book recorded when work was required and it was signed and dated when the work was completed. There was evidence that carpets had be replaced in some areas of the home and rooms decorated, the dining room on the dementia unit been redecorated and a new floor had been laid in the main kitchen. Records showed that Legionella testing was carried out annually. Water outlets in bedrooms were tested and the water temperature recorded. The “Nurse call” system tested positive. The laundry was situated in the basement of the home. The housekeeper explained the laundry procedure. She confirmed that the washing machines met the required standards. Cleaning materials were stored in a locked room in the basement and information relating to the Control of Substances Hazardous to Health (COSHH) procedures were seen. All parts of the home were odour free and a contract was in place for the removal of clinical waste. Domestic staff explained their roles in respect of the cleaning of bedrooms and communal areas. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Staff were recruited using current guidance and the company’s equality and diversity policy. They were offered training that was suitable to meet the diverse needs of the current residents. EVIDENCE: There were designated staff for each unit. Each unit had its own rota, which showed the name of staff and the hours they worked each day. There were sufficient numbers of staff on duty to meet the diverse needs of the residents. Staff spoken to said that there was generally enough staff on duty for them to do all the things that they needed to do. Ancillary staff were employed so that there was a Cook, Kitchen Assistant and Domestic on duty each day. A Handyman was also employed. It was recommended that the senior person on each shift should be identified on the rota, if the manager or senior staff were not on duty – eg the night time rota should identify the person in charge who would take charge in the event of an emergency. Two of the ancillary staff had been employed after retirement age under the company’s Diversity and Equality policy. The company also employs staff from overseas. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 19 Of the nineteen care staff, records showed that ten had completed the National Vocational Qualification at level 2 (or equivalent). This meant that 52 of the care staff had the knowledge to enable them to do their work in a competent manner. Places had been obtained for further staff to undertake this training. The files for three staff members were viewed. All prospective employees completed an application form and had a face-to-face interview. A Criminal Records Bureau clearance was completed. A POVA First check had been completed prior to employment. Two references were requested and received for all prospective employees. All new staff received a copy of the Staff Handbook and the General Social Care Council code of conduct and practice. Staff confirmed that they received Induction training and Foundation training based on the Skills for Care Standards. Training records were available to examine and showed a variety of training being offered. Staff said that training needs were identified during their supervision periods. Although dementia training was offered to staff, training records showed that not all staff who worked in the dementia unit had completed this training. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31:33:35:37:38 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The welfare of residents was sufficiently protected. The home was run in an open and transparent way with a good staff and management team. EVIDENCE: The manager is appropriately qualified with a number of years experience, having previously been registered as a manager in another registered home. She has been employed at Acorn House since January 2007 but has yet to make an application to the Commission to be registered. She spends 4 days a Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 21 week as manager and the other day as a Senior Carer in the Dementia Unit. Lines of accountability appear in the Statement of Purpose. Records showed that the management team were committed to Quality Assurance issues, holding the Blackburn with Darwen Quality Assurance Award, addressing comments raised in client questionnaires and surveys and from these developing a Quality Assurance programme and annual development plan. The Operations Director makes regular visits to the home. She completes the appropriate documentation required by legislation. Families or advocates were responsible for the payment of fees. Some residents chose to manage their own personal allowances. Monies were held individually and securely and records examined, were retained in respect of any transactions. Transactions showed two signatures. A variety of files, containing different documentation was held for each person resident in the home. However there was concern about the recording of an accident to one resident. Information held in the persons file did not match information written in the accident book. Training records evidenced that staff members had participated in training relating to safe working practices. Infection control procedures were available. Records showed that regular servicing of equipment takes place by authorised and qualified contractors. Cleaning materials were stored safely. The Operations Director felt that the home complied with relevant legislation. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x X 4 X x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 3 4 X X X X X x 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 4 x 2 3 Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 23 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. Refer to Good Practice Recommendations Standard 1. OP7 The care plans should be written with enough detail so that staff are aware of all actions to be taken in a situation. These should include the plans of people staying in the home on a short stay basis. 2 OP7 All concerned should sign reviews. In addition to staff, residents and or their relatives if present should be asked to indicate their involvement with decisions reached. 3 OP27 The senior person on shift should be identified on the rota if the manager or senior staff are not on duty – eg the night time rota should identify the person in charge to take responsibility in case of an emergency. 4 OP30 Training on dementia care should be arranged and made available to all staff on Oak Tree unit. 5 OP31 The manager should apply for registration with the Commission. 6 OP37 Staff should take more care when referencing and recording information relating to accidents. Acorn House Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Care Centre DS0000022479.V335803.R01.S.doc Version 5.2 Page 25 - 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. 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