Inspection on 18/10/07 for Acorn Lodge

This inspection was carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Lodge 29/11/06

Acorn Lodge 23/11/05

Acorn Lodge 14/07/05

Acorn Lodge 05/10/04

Acorn Lodge 09/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Acorn Lodge Turners Hill Road East Grinstead West Sussex RH19 4LX Lead Inspector Mrs J Hough Unannounced Inspection 18th October 2007 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 Lodge DS0000024100.V347493.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 Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Lodge Address Turners Hill Road East Grinstead West Sussex RH19 4LX 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) 01342 323207 01342 313742 Acorn Health Care Limited Mrs Mary Ann Wattam Care Home 33 Category(ies) of Dementia (33) registration, with number of places Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 33 male and female service users in the category of Dementia to be admitted / accommodated. Date of last inspection 11th January 2007 Brief Description of the Service: Acorn Lodge is a care home providing personal care and nursing for thirtythree residents in the category of elderly dementia care DE(E). The registered provider is Acorn Healthcare Ltd. The Responsible Individual is Mr V Ghugroo and the Registered Manager is Mrs Mary Wattam. The home is a large detached property located just outside the town of East Grinstead, West Sussex. The accommodation is provided in seventeen single rooms and eight double rooms, arranged over three floors. A vertical lift provides access to all floors. Communal facilities include four lounges and a dining area located on the ground floor. There are extensive grounds with private car parking to the rear of the property. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. June Hough Regulatory Inspector carried out the unannounced inspection on 18th October 2007 at 09:30 hours until 15:15 hours. Time was spent during the inspection talking to the residents living in the home, staff on duty, and the registered manager. We met residents and staff in the communal areas of the home, and some resident’s rooms, and we also visited the kitchen. Two resident’s care plans, assessments and care notes, medication records, complaints, accidents, staff training records and staff files were read. The registered manager of the home had completed an Annual Quality Assurance Assessment (AQAA) prior to the visit and five survey forms received from families made positive comments about the home. The registered manager and responsible individual for the home were present to receive feedback. Requirements from the last key inspection on 29th November 2006 had been met. Two recommendations have been made regarding care plans and activities following this key inspection. Current fees are from £600.00 to £660.00 per week. What the service does well: Acorn Lodge provides an attractive, homely and comfortable environment for residents. Feedback from relatives and comments made by some residents show the staff team are committed and caring and residents are treated with kindness and respect. The home is run well by an experienced and qualified manager who is approachable and available to residents, relatives and staff. Staff are given the training necessary for their work and all staff have regular supervision. Residents are offered a variety of good home cooked meals. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A needs assessment is carried out before new residents move into the home. Residents are provided with a contract of terms and conditions of residency prior to moving into the home. EVIDENCE: Pre-admission assessments for two new residents contained comprehensive information about the support needs the resident would require and had been completed with input from the resident’s relatives. The home provides each resident with a contract setting out the terms and conditions of residency and the contracts had been signed by a relative or representative. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place although they need further development. Medicines are stored and administered safely. Staff treat residents with respect and there right to privacy. EVIDENCE: Two care plans and assessments were tracked. The residents care plans did not reflect all the information written on the needs assessment prior to admission. It was not clear from reading the handling assessments what actions staff needed to take when transferring and moving residents. Care plans needed further development to ensure the care provided was documented. Feedback received from relative surveys and from observations of residents showed the residents are well cared for and their needs are fully met. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 10 Comments such as “staff are wonderful and look after my relative very well” and “staff take care of residents needs and give them their fullest attention”. And “every assistance is given for comfort and care” In order to ensure that the healthcare needs of residents living in the home are met, other healthcare professionals are involved where necessary. The home has a supply of pressure relieving equipment that includes mattresses and cushions. There is one mobile hoist, three hospital beds and two electric beds. Staff have received training on wound care and further training is planned for the future. Medication administration records were all signed to date and medication appropriately stored. Medicines are supplied in blister packs and administered from the medicine trolley. All medicines disposed of are recorded in a book initialled and dated. It was advised that medicines given as required also be recorded on the reverse side of the medicine administration record to monitor the reasons for giving and how effective the medicine is. Following a pharmacist inspection from the Commission of Social Care Inspection in January 2007 the home had taken the necessary action to meet the requirements made. Controlled drugs are stored and recorded appropriately. None of the residents accommodated are capable of keeping or taking their own medicines. Staff are aware of the need to treat residents with respect when giving personal care. Feedback given on a relative’s survey says, “ I feel the staff treat my mother as an individual and with great respect”. Observations made of staff interacting with residents showed they are caring and respectful. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A limited choice of activities is provided for residents. Residents are able to have visitors at any reasonable time. Residents have the choice of good home cooked meals. EVIDENCE: The home provides some activities for residents such as music for health every four weeks and reminiscence. Birthdays and seasonal events are celebrated and a garden party arranged during the summer. Staff are responsible for arranging activities in the afternoon such as reading, hand massage etc. No activities were seen taking place during the inspection although staff were sitting with residents in the lounge. Resident’s interests are not recorded on care records and no planned programme of activities was in place. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 12 The manager and staff said it was often difficult to get residents to join in with activities, as they often did not want to participate or lacked concentration. Therefore, the activities presently on offer need reviewing to ensure residents are given further opportunities for stimulation in line with their interests and hobbies. Residents are supported to maintain links with family and friends and visiting times in the home are open. Relative’s comments on surveys showed that the home keeps them well informed about matters to do with their relative or the home. Menus are planned for a five-week period and offer residents a choice of good home cooked food. Menus are developed with the cook and manager taking into account residents likes and dislikes in food. The home provides special diets as required. Residents able to comment on the food said it was nice. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are recorded and acted upon following the home’s complaint procedures. The staff are aware of adult protection issues and have received training. EVIDENCE: The complaints procedure was displayed in the hallway of the home. Responses on relative’s surveys showed they did know how to make a complaint. The manager confirmed that the residents able to express their wishes and needs speak with her if they have any concerns or complaints. All complaints or concerns are recorded in a logbook and records show that there had been two complaints since the last inspection in November 2006 and both had been resolved satisfactorily. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 14 Staff spoken with confirmed that they have updated and regular training on the Protection of Vulnerable Adults (POVA) and all understand their individual responsibilities for reporting any incidents. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and homely environment for residents. EVIDENCE: Acorn Lodge is homely, comfortable and a well maintained care home. Communal areas, the kitchen and some of the resident’s rooms were seen and all areas were clean, fresh and tidy. Relative’s comments on recent surveys said “Acorn Lodge is in beautiful surroundings and well kept” and “on visiting the home on different days and different times of day we have always found the home to be spotlessly clean”. Domestic staff work each day and a laundry assistant works five days per week. The home has an on-going maintenance programme and future plans are to add seven more en-suite bedrooms and extend the lounge. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 16 Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff working in the home to care for the current residents. Residents are supported and cared for by committed and well-trained staff. The home carries out thorough recruitment checks to ensure residents are protected. EVIDENCE: Staff rota’s show that six members of staff work on each shift during the day, two of which are qualified nurses. At night there is a qualified nurse plus two care assistants. On speaking with staff on duty it was agreed that staffing levels are sufficient for them to care for the thirty residents accommodated. However it was felt that staff and residents would benefit from having a kitchen assistant to help with supper. The manager confirmed that staffing numbers are arranged according to the number and dependency of residents. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 18 The home has a minimum staff turnover, and many of the staff have worked in the home for some years and all said they liked working in the home. Staff spoken with confirmed they have regular mandatory training and all staff have training on dementia care. Staff are encouraged and supported to obtain the National Vocational Qualifications (NVQ) in Care, and over 50 of care staff have gained the qualification. Staff files of two new members of staff were checked and both files contained the relevant checks and information. However it was advised that the application form for new staff should include a more detailed record of previous employment. New staff commence the “Skills for Care” induction programme during the first six weeks of employment. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced and qualified manager. Staff are supervised and given the appropriate training for their work. The home regularly asks relatives their views on the home by sending out surveys at least once a year. The general health, safety and welfare of residents and staff are promoted. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager has managed the home for several years and is a qualified Registered Mental Nurse (RMN) and has gained the Registered Managers Award.(RMA). Relatives and staff said that the manager was supportive and caring. One staff member said, “The manager is very approachable and takes time to listen to the team” Relative’s comments on a recent survey said, “ we feel the home is well managed as the manager and staff are very approachable and friendly”. Quality assurance surveys were sent out to relatives in June 2007 and comments and responses were positive. The manager and staff confirmed that formal staff supervision takes place at least six times a year. Both the manager and the trained nurses are responsible for arranging and carrying out the supervision of staff. The Annual Quality Assurance Assessment showed that all equipment and systems in the home are serviced and maintained at appropriate intervals. All accidents and incidents are recorded and reported to the appropriate authorities. A trained nurse is responsible for monitoring the number and frequency of accidents and any issues are discussed with the manager for action. The home has a planned training programme for staff and training is on-going and carried out by an external training company. Policies and procedures are in the process of being reviewed and updated as necessary. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 21 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 X 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 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP7 Good Practice Recommendations Develop an activity programme in line with resident’s interests and designate a member of staff to take responsibility for activities during the afternoons. 7.2 - The Service User’s plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the Service User (see standard 3) are met. Acorn Lodge DS0000024100.V347493.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000024100.V347493.R01.S.doc Version 5.2 Page 24 - 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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