Inspection on 01/06/07 for Acorn Lodge

This inspection was carried out on 1st June 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Acorn Lodge 09/05/06

Acorn Lodge 25/10/05

Acorn Lodge 21/06/05

Acorn Lodge 07/10/04

Acorn Lodge 20/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Acorn Lodge 361 Ewell Road Surbiton Surrey KT6 7BZ Lead Inspector Adrian Gordon Key Unannounced Inspection 1st June 2007 10:30 Acorn Lodge DS0000013386.V341582.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 Lodge DS0000013386.V341582.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 Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Lodge Address 361 Ewell Road Surbiton Surrey KT6 7BZ 020 8296 9633 02082969622 info@carewatchltd.co.uk 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) Mr Younoos Jeetoo Mr Alfred Nii Okine Tagoe Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Acorn Lodge is a privately owned home registered to provide residential care for up to ten adults with learning disabilities. The home is located in a residential road in Surbiton. There are good local bus links to surrounding areas and Surbiton rail station is nearby. Shops and local facilities are easily accessible. Information about the service is available in the Statement of Purpose and Service User Guide. The current range of fees is £595 to £1000 per week. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over the course of one day. The inspection consisted of a tour of the premises, examination of records and observation of care practice. We met with five residents, one member of staff and the manager. Feedback questionnaires were received from seven residents and three relatives. What the service does well: What has improved since the last inspection? What they could do better: The majority of residents are able to be largely independent but more must be done to ensure that each resident works towards their own goals, developing personal skills. Staffing levels remain low and this must be reviewed to ensure that all residents have all the support they need to meet individual needs and goals. The system for recording complaints must be improved to ensure it is only used to monitor concerns raised by residents and their representatives, together with outcomes of any investigation. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 6 The quality assurance system is still being developed, but to make sure residents can see the benefit of giving their views, an action plan must be put in place after any consultation. To make sure that staff have the skills they need to carry out their roles a training programme must be put in place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 8 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): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Current residents are confident their needs can be met, but the home must ensure that it is correctly registered for the service it provides. EVIDENCE: There have been no new admissions over the past year. Prospective residents receive a full assessment before admission to make sure the home is suitable. All the current residents have lived there for some time and although the service is able to meet their needs there are some people whose diagnosis falls outside the category for which the home is registered. It is unclear how this situation arose but the registered persons must make sure the certificate of registration accurately reflects the service provided. This must also be reflected in the Statement of Purpose and Service User Guide. Contracts and terms and conditions are in place, and have been signed by residents. This ensures that they are clear about their rights and responsibilities. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 9 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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by good person centred care plans which are regularly monitored and reviewed by staff. EVIDENCE: Person Centred Plans are in place for each of the residents. These contain a lot of useful information in sections which include ‘about me’, important people, likes/dislikes. ‘how I make choices’ and life story. These are signed by residents and kept up to date. Care plans are also very detailed and explain how each area of need should be met by the staff. However, there was nothing about relationships and sexuality. More must be done to make sure that residents emotional needs are fully met. Care plans are all up to date and regularly reviewed, except for one person who had not had a review for two years. The manager said that he had tried to arrange this but there was a lack of support from the care manager. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 10 Keyworkers write a monthly report on each resident which includes an overview of the month, changes to the care plan and an action plan. This is good evidence that residents needs are regularly monitored and reviewed. Residents are encouraged to become involved in the running of the home and to make decisions about what they want to do. On the day of inspection one person had decided to stay at home from day centre and their wishes had been respected by staff. Resident meetings take place regularly and minutes show that there is good participation. Risk assessments are in place for all people that live at the home and cover areas such as road safety, self neglect, fire safety and manual handling. Independence is generally encouraged, however one resident who liked to do things for themself said ‘staff sometimes do things for me and I would rather they didn’t’. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a good range of activities but more must be done to enable individuals to choose what they want to do and have these choices carried out. EVIDENCE: Residents are able to access a range of activities in the community. Some people attend Geneva Road day centre where they can learn computer skills, music and gardening. Other people go out independently to cafes, shops or the pub. Some residents regularly visit family at weekends. One resident said they ‘enjoy the freedom’. A holiday is being planned for later in the year to the Isle of Wight for everyone that wants to go. The home has use of a minibus which is shared Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 12 with two other homes, however a complaint from last year suggest that it is not always available when needed. It was unclear what action was taken as a result of this complaint. Relatives are made welcome and can visit when they wish. However, on questionnaires sent out by the manager to residents, one person felt that they could not have friends over for a meal or overnight. This is similar to comments received at the last Key Inspection. The manager must ensure that residents are aware of their rights and that there are no unnecessary restrictions on having friends come to visit. The residents’ phone has been broken for two weeks. They were able to use the office phone as an alternative, but someone commented that there can pressure to be quick. On the day of inspection one resident went out to buy a mobile phone. It should be considered whether this was an option for all residents without disadvantaging them financially. Feedback from residents on the meals offered was positive. Menus showed a good range of food which all residents spoken to said they enjoyed. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 13 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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health of residents is promoted through good information in care plans and the support from external specialists. EVIDENCE: The majority of people who live at the home do not require any support with personal care. All residents spoken to said that if they needed support with something they would ask a member of staff. One residents wheelchair was being stored in the staff room which is kept locked. Although this was for security reasons, it does not maintain the residents independence and is against their wishes. More accessible storage must be found. There is good support in place to meet the health needs of residents. Records are kept of visits and appointments to the optician, GP and dentist. Suitable external support is also available from specialists such as speech therapist, community learning disability team and community mental health team. Health Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 14 Passports, which describe each residents health needs in person centred way are currently being put in place. Medication profiles give details of medication taken, possible side effects and any allergies. These were all up to date and clearly written. All other medication records were seen to be correct at the time of inspection. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 15 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): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to express their views, however the system for recording complaints does not always make it clear how these views are acted on. EVIDENCE: All residents spoken to were aware of how to make a complaint. A record of complaints is maintained but it is not always clear what action has been taken or whether this was satisfactory to the person that complained. A separate book is kept which describes action taken for some of the complaints. This system is confusing and does not make it easy to track a complaint from start to finish. Staff also use the complaints book to record concerns about behaviour or abusive language of residents. This was discussed with the manager who felt it was important for staff and residents to be treated equally. However, if staff wish to make a complaint this should be taken up through separate procedures. Any concerns about residents behaviour must be recorded as incidents in individual residents’ files. There are policies and procedures in place for the protection of vulnerable adults (POVA). There have been no recent allegations. Staff POVA training took place in September 2006. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 16 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): 24, 25, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a homely environment which is suitable for their needs. EVIDENCE: Acorn Lodge is a two storey building located on a busy road close to local shops and facilities in Surbiton and Tolworth. Local buses stop close to the home. The building is in the same style as neighbouring residential houses. Communal areas are on the ground floor and include a kitchen, open plan dining area and sitting area and separate lounge. All areas of the home were clean and tidy and comfortably furnished. Some repainting had recently been done, in colours which the residents helped to choose. However one resident felt the pictures were old fashioned. To the rear of the property is a good sized garden area. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 17 Bedrooms are suitable for the people that live their. They are able to make them personal with pictures, photos and ornaments. Residents said that they were able to choose the colour for their bedroom, although one person said that it was not the colour they had picked. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 18 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): 31, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by good recruitment monitoring. Staff get on well with residents but will be better supported by having their training needs assessed and met. EVIDENCE: The members of staff on duty were observed to get on well with residents, being relaxed, friendly and listening to what was being said. One resident commented that ‘staff are good’. Staff levels are limited and there is usually a maximum of two staff on duty. This can mean that residents sometimes have to wait for attention. There is a good range of training available, which over the last year included moving and handling, epilepsy and managing challenging behaviour. However, there was no training plan for the current year. This must be put in place to ensure staff have the specialist skills they need to carry out their jobs. Core training, such as medication administration must be refreshed every year. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 19 Recruitment records are kept centrally. These were seen to be carefully monitored to ensure that all staff have the necessary checks. Criminal Records Bureau disclosures are in place, however in order to better protect residents, these should be renewed every three years. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 20 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): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management ensures that residents are kept safe. Residents are encouraged to give feedback on the service provided but are not always aware of how this feeds in to future developments. EVIDENCE: The manager showed a good understanding of the needs of the people that live at the home and was observed to have a positive relationship with staff and residents. Questionnaire forms have been created for residents, relatives and other people with an interest in the home, to give feedback on the service provided. The manager said that a formal quality assurance review was still in progress Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 21 and that relatives and care managers did not always respond. Some forms which had been filled in by residents were seen, however it was unclear what action had been taken as a result of these. Health and safety checks are up to date apart from a gas safety inspection which was due in March 2007. The manager said this was due the boiler being changed. The fire alarm system was tested in May2007 and there are weekly fire point tests. Fire drills every three months make sure that residents and staff follow procedures correctly. Control of Substances Hazardous to Health (COSHH) materials are stored safely and information sheets are available. Acorn Lodge DS0000013386.V341582.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 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 6 and Care Standards Act 2000. Part II, 24. 15 Requirement In order to ensure that information about the home is accurate, the certificate of registration must show the service provided, and the Statement of Purpose and Service User Guide updated to reflect this. In order to better meet residents emotional needs, care plans must include information on relationships and sexuality. To support residents maintaining contact with friends and relatives, there must be access to suitable telephone facilities which can be used in private. The service must ensure that residents are aware of their rights to have visitors in the home without unnecessary restrictions. To maintain the independence of residents, accessible storage must be found for specialist equipment that is used. The record of complaints must show a clear audit trail of action taken and outcome for the complainant. It must only be DS0000013386.V341582.R01.S.doc Timescale for action 31/07/07 2 YA6 15/08/07 3 YA15 16(2)(b) 15/08/07 4 YA15 16(2)(m) 31/07/07 5 YA19 12(2) 31/07/07 6 YA22 22 31/07/07 Acorn Lodge Version 5.2 Page 24 7 YA35 18(c) 8 YA39 24 used for complaints made by residents or someone acting on their behalf. In order to make sure staff have 31/08/07 the necessary skill and competence all core training must be carried out once every year. There must be an effective 31/08/07 quality assurance system in place to ensure the home is meeting it’s stated aims and adjectives. This must include a summary of any consultation and an action plan for the future. This requirement is reinstated from the last inspection. To further protect residents, a gas safety inspection must be carried out. 9 YA42 13(4) 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA9 YA33 YA34 Good Practice Recommendations To promote the independence of people who live at the home, staff should consider whether any support they give is always needed or requested. To ensure that residents have the support they need at all times, the staffing levels should be reviewed. To further protect residents, Criminal Record Bureau Disclosures should be renewed every three years. Acorn Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Lodge DS0000013386.V341582.R01.S.doc Version 5.2 Page 26 - 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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