Inspection on 23/11/05 for Acorn Lodge

This inspection was carried out on 23rd November 2005.

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 18/10/07

Acorn Lodge 29/11/06

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 23rd November 2005 10.25 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.V258918.R01.S.doc Version 5.0 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.V258918.R01.S.doc Version 5.0 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 Acorn Health Care Limited Mrs Mary Ann Wattam Care Home 33 Category(ies) of Dementia (33) registration, with number of places Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 33 male and female service users in the category of Dementia to be admitted / accommodated. No service users under the age of 65 years to be admitted. Date of last inspection 14th July 2005 Brief Description of the Service: Acorn Lodge is a care home providing personal care and nursing for thirtythree residents in the category DE(E), persons over the age of 65 years with dementia. The home is a large detached property located in the town of East Grinstead, West Sussex. The accommodation is provided in 17 single rooms and 8 double rooms, which are arranged over three floors. A vertical lift provides access to all floors. Communal facilities include three lounges and a dining area located on the ground floor. There is a large garden and private car parking to the rear of the property. The service is privately owned by Acorn Health Care Ltd. The responsible individual acting on behalf of the company is Mr.V. Ghurgroo. The registered manager is Mrs Mary Wattam who is responsible for the day- today running of the home. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 5 hours and the Responsible Individual Mr.V.Ghurgroo and the Registered Manager Mrs.M.Wattam were present at the inspection and provided the information required. A tour of the premises was carried out and some of the resident’s rooms were seen. Four of the resident’s care plans and assessments were read and records were examined of accidents, complaints, maintenance checks, medication, staff recruitment and staff training. Four members of staff and two visitors were spoken with. Due to the mental frailty of the residents it was not possible to obtain their views of the home. It was therefore necessary to rely on observations, discussions with staff and examining the care records to determine if the residents are being well cared for. Not all the standards were assessed at this inspection. The standards not assessed were fully met at the last inspection in July 2005. What the service does well: What has improved since the last inspection? Training on dementia and challenging behaviour had taken place for all staff in October 2005. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 6 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 Lodge DS0000024100.V258918.R01.S.doc Version 5.0 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.V258918.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 & 5 The Statement of Purpose and Service User Guide needs revising. The terms and conditions of residency is in the process of being updated. The staff have the knowledge and skills to care for the residents. EVIDENCE: The Statement of Purpose and Service User Guide needs updating to reflect the current building and improvements to the premises and a copy sent to the Commission of Social Care Inspection (CSCI). All the residents have a copy of the terms and conditions of residency and these are currently under review. The staff training records examined showed that the staff had completed training in dementia and challenging behaviour in October 2005. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 11 The residents are well cared for. EVIDENCE: Five of the resident’s care plans and assessments were read and all gave a detailed account of the resident’s needs and the level of care and assistance they required. The social care needs of the residents were recorded in those cases where the relatives were able to provide the information. Nutritional assessments were not completed in all cases. The resident’s weight was monitored each month and the care plans reviewed every 3 months or sooner if the resident’s care needs change. The care plans gave no evidence of the involvement of the resident where able or a representative in the writing up of the plans. None of the residents have been assessed as capable of taking and keeping their own medicines, and the trained nurses have taken on this responsibility. Generally the medication records were well maintained and all medicines were stored and disposed of following the medication procedures for the home. Handwritten entries on the medicine administration records were not signed and dated in all cases. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 10 The home can access specialist equipment when needed and a pressure relieving mattress and cushion needed for one resident was obtained promptly as soon as the need was identified. The home has a policy for death and care of the dying to enable the staff to understand their responsibilities at these times. The home strives to continue to care for the residents during their final days wherever possible, unless there are strong medical reasons that prevent this. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Visitors are welcome in the home. Activities take place to suit the needs of the residents. The home offers a good choice of home cooked food. EVIDENCE: The home does not employ an activities organiser as the staff carry out activities and stimulation for the residents taking into account their individual capabilities. Activities may be sitting with the resident talking, reading or playing a game such as throwing a beach ball to each other. A music session is provided every two weeks called music for health. Visitors are made very welcome to the home and the home has an open policy for visiting which asks visitors to avoid mealtimes. However visitors are welcome to have a meal with the residents as long as the home is notified in advance. None of the present residents are capable of handling their own financial affairs and money and have relatives or a representative who takes on this responsibility. The home does not get involved in the financial affairs of the Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 12 residents and only deals with small amounts of spending money. All transactions carried out are recorded and signed for and receipts kept where appropriate. The registered manager is the only person who handles and deals with these small amounts of money. Menus for the period of five weeks provided a well-balanced and varied choice of food and special diets are well catered for. The menus are reviewed as necessary taking into account the likes and dislikes of the residents. The kitchen was clean and tidy and the food stored appropriately. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 The home has a clear and accessible complaints procedure. EVIDENCE: No complaints have been recorded since the last inspection in July 2005. The complaints procedure is displayed in the home and contained in the Service User Guide. The procedure gives all the details on how and to whom to make a complaint and the process that follows. The home provides information on advocacy services that is displayed in the home for reference. None of the present residents are able, or have asked to vote at elections. However, postal voting would be made available as necessary. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 14 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): 20,21,22,23,24,25 & 26 The home is comfortable, homely and well maintained. EVIDENCE: There are three lounges in the home and a separate dining room. The furnishings and décor are of a good standard and many improvements have been carried out recently with re-decoration and completion of the new extension. The home was clean and fresh on the day of inspection and two visitors said that at every visit they noticed there was a high standard of cleanliness in all areas of the home. There are sufficient toilets and bathrooms for the number of residents living in the home. The home has the equipment that is necessary at present, with one portable Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 15 hoist. Grab rails are fitted in the appropriate areas and there is a passenger lift giving access to all floors. The resident’s bedrooms are furnished to suit their individual requirements taking into account their comfort and safety. Call systems are fitted in all the resident’s bedrooms and each resident is risk assessed as to their capabilities of using the system. In the new extension all bedroom doors are fitted with locks but again the residents are risk assessed for their suitability for having a key. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 16 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): 28 & 29 The staff are qualified and experienced to care for the residents. The recruitment procedures for the home were not followed in one case. EVIDENCE: The care staff working in the home are encouraged and supported to do the National Vocational Qualifications (NVQ) in care. The home employs eleven care workers, seven of which have gained the NVQ qualifications, with two other care workers working towards the qualification. New staff to the home have the necessary checks carried out prior to starting work in the home. However one staff file showed that a new member of staff had no evidence of having two satisfactory references or a satisfactory Criminal Records Bureau check. The member of staff in question is working in the home under constant supervision. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 17 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): 32,33,34 & 38 The home is well run and managed taking into account the welfare of the residents. The home protects the residents and staff from harm as far as practicable. EVIDENCE: The registered manager Mrs Wattam runs the home in such a way that the staff and relatives are able to have contact and speak with her at anytime. Close contact is maintained with relatives and visitors wherever possible. The staff spoken with said the manager supports them in their work and includes them in any decision making within the home. From observations on the day it was clear that the nursing and care team work well together. The home sent out questionnaires to the relatives at the beginning of 2005 and had four responses all of which gave positive feedback. A valid certificate of insurance for the premises was displayed in the home. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 18 Maintenance records showed that all equipment and systems were serviced and maintained within appropriate timescales. All accidents, injuries and incidents were recorded and reported to the appropriate authorities. The home ensures that all the staff attend the mandatory training within the required timescales. Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 19 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 2 3 x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x x 3 3 3 3 3 3 x STAFFING Standard No Score 27 x 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 3 x x x 3 Acorn Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 20 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. 1 Standard OP29 Regulation 19 Requirement The registered person shall not employ a person to work in the care home unless full and satisfactory information is available in relation to references and a satisfactory CRB check. Timescale for action 30/12/05 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 Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Lodge DS0000024100.V258918.R01.S.doc Version 5.0 Page 22 - 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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