Inspection on 25/10/05 for Acorn Lodge

This inspection was carried out on 25th October 2005.

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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Acorn Lodge 01/06/07

Acorn Lodge 09/05/06

Acorn Lodge 21/06/05

Acorn Lodge 07/10/04

Acorn Lodge 20/04/04

Similar services:

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Norbury Crescent (30)

Edenvale

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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 Michael Stapley Unannounced Inspection 25th October 2005 11:00 Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 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.V254767.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 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.V254767.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Acorn Lodge Address 361 Ewell Road Surbiton Surrey KT6 7BZ 020 8296 9633 02082969622 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 vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th May 2003 Brief Description of the Service: Acorn Lodge is a privately owned home managed by a private company. The home is registered to provide residential care for up to ten adults with learning disabilities. At the time of the inspection there were eight service users at the home with two vacancies. The current service users have mild to moderate learning disabilities. The premises are a modern purpose built two-storey house set back in a residential road in Surbiton. There are good transport links to Kingston upon Thames and the surrounding area. The home also benefits from having its own people carrier. There is a large communal lounge on the ground floor as well as a spacious kitchen and dining room. The home is homely, bright and clean. The furniture is domestic, flame retardant, and of good quality. The home is fully accessible to all of the service users. The home has parking to the front and a pleasant garden at the rear of the home which the service users spend time in during the summer months. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 25th October 2005. There has been a change in management at the home in the last year. Alfred Tagoe is the current acting manager supported by a consultant Mike Hale. The home has been without a permanent manager for nearly eight months, which is clearly a situation that has to be resolved without further delay. The current acting manager advised the inspector that he would be submitting his application for registration as manager of the home to the commission shortly. Given the length of time the home has been without a permanent manager the application must be submitted within twenty-eight days of this inspection. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the acting manager who will be sending an action plan to the commission as agreed at the time of the inspection. What the service does well: What has improved since the last inspection? Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 6 The acting manager, Mr Alfred Tagoe commenced his duties at Acorn Lodge on 29th September 2005. He is an experienced and qualified manager who has previously managed a similar home. In the month he has been at the home he has begun to address shortfalls within the home. In discussion with the inspector it was evident he plans to introduce monthly reports for service users which will be compiled by key workers. A new format for supervision is planned and service user’s questionnaires have been drawn up and distributed. Some responses have been received and the manager plans to meet with all the service users to address issues that they have raised. The manager also has plans to review staff training and development given the lack of trained staff. Initially he plans to use the staff meetings at the home to improve communication amongst the team and discuss basic care values. The home has a complaints procedure both in written and pictorial form that has now been developed in the form of a video. However the inspector expressed concern as it would appear the complaints process was not being used and was in a loose leaf file. See standards 22 - 23 for further comment. There have been improvements in the environment with refurbishment and redecoration having taken place. What they could do better: While the inspector noted that the acting manager is to make an application to the commission for registration as the permanent manager the registered providers must ensure the application is submitted within twenty-eight days. Notwithstanding the recent appointment of Mr Alfred Tagoe it is noted that he is the third manager of the home within the last nine months. The registered providers must ensure in so far as is practical that there are know further management changes. This is essential if the home is to develop sound working practices and a clear vision for the future. Care plans still need to be further developed in conjunction with service users and relatives/friends. They should be reviewed to include all elements of Standard Six. Personal Centre Plans for service users have not been introduced in the home and only one member of staff has been on the introductory training course in respect of Person Centred Planning. Contracts for service users did not contain all the information required under standard five. There was a lack of key worker training and although the registered providers agreed that the format of supervision needed changing the requirement was still outstanding. In addition staff were not having one to one supervision meetings six times each year. In addition there were no notes of one to one key working meetings with service users Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 7 The home has not developed a quality assurance system although it has started to seek the views of service users. However the views of care managers, other professionals and stakeholders had not been sought and the home had not carried out an annual audit. Requirements have therefore been made in respect of these standards In addition the inspector expressed concerns that the pharmacist had not inspected medication for over twelve months and requirements made at that inspection were still outstanding. There was no evidence to suggest the fire extinguishers at the home had been serviced and outdated food was found in the fridge. An action plan to address the inspection of 21st June 2005 was received by the commission on 10th October 2005. Unfortunately timescales to comply with standards and regulation were not given. Thus the majority of requirements from the last inspection remain outstanding. 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 DS0000013386.V254767.R01.S.doc Version 5.0 Page 8 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.V254767.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users do not contain all the information required under standard five potentially reducing the rights of the residents of Acorn Lodge. Staff at the home have not had appropriate training for working with service user’s with a learning disability and those service user’s who are non verbal. This could clearly have an impact on the delivery of the service to residents at the home. EVIDENCE: The home has a preadmission procedure including a resident’s charter. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. One of the service users files was inspected at random. The inspector noted it contained an assessment that had been completed by a care manager and included additional assessments from other professionals. While the home has a training programme there is know evidence to suggest that staff have received training for the particular client group they are working with. Staff should receive specialist training for service users who have a learning difficulty such as that provided by LADAF. There has been some progress in improving contracts between the home and the service users. Contracts now stated that all residents would have a threeAcorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 10 month ‘settling in’ period of residence at the home. However they still did not contain all the information as required under standard 5.2. The home must accordingly amended service users contracts without further delay, as at present there is the potential for their rights to be reduced. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service user care plans do not contain all the information required therefore staff at the home do not have all the information they require to satisfactorily meet the needs of the service users. They had also not been developed with the involvement of the service users, family, friends and advocates that could result in their rights being eroded. Generally service users have had individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Service user individual care plans are not at all comprehensive and do not contain all the elements of standard six. Care plans, as a minimum should include a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are not involved in drawing up such plans as outlined in standard 6.6. In addition although service users have a key worker there was no evidence of one to one key worker meetings. The acting manager explained that the home plans to Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 12 move towards Person Centred Plans where ownership of the plan is given to the individual service user. While this is to be commended it was noted that only one member of staff had undertaken Person Centred Planning training at the home. It is suggested that each service user has a Person Centred Plan that is reviewed and completed every six months. Service users files sampled at random all had individual risk assessments and risk management strategies. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14, 15, 16 and 17 The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. Staff support service users to maintain family links and friendships both inside and outside of the home, subject to any restrictions agreed in the individual plan and contract. The daily routines of the house seek to promote independence, individual choice and freedom. EVIDENCE: The home is supporting service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, local leisure facilities and shops. In addition to swimming, gym and dancing. The home has now acquired its own people carrier that has made accessing activities a great deal easier. The Staff team are available to support service users while accessing community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. Although service users do Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 14 not at present have access to a computer the registered person explained at the announced inspection that this would be considered. At the time of this inspection there was no evidence to suggest this had been followed up. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. The inspector noted foodstuffs past there ‘use by’ date in the fridge and noted that cereals were not appropriately packaged in sealed containers. While the home seeks to promote family links and friendships both inside and outside of the home some of the service users who returned questionnaires felt that were restrictions on where they could see friends. Further the home needs to ensure service users can develop and maintain intimate personal relationships. The acting manager advised these issues were to be addressed at the next service users meeting. Likewise while the home aims and objectives are to promote independence, choice and freedom there was a number of questionnaires returned that stated they did not have a key to the front door. The acting manager agreed to clarify these issues at the next service users meeting. Standards 15 and 16 will therefore need to be further reviewed at the next inspection. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is reasonably well managed to ensure good health. However the homes pharmacist last inspected the homes medication and associated procedures in September 2004, recommendations for good practise from that inspection have not been complied with. EVIDENCE: Health records are maintained for each service user. Service users records examined during this inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. All service users are registered with a local General Practitioner. The home employs the Boots blister pack system and the local pharmacist visits the home to offer advice. The last visit was in September 2004 during the visit a report was made which clearly stated that the date on which tubes and tubs are opened must be duly recorded given their limited shelf life. The inspector noted tubes and tubs of cream without the date of opening on them. The staff team at the home now keep an individual record of incidents on service user’s files. Staff members monitor service user’s health and maintain up to date records. All of the staff team have received in house medication training. However this is not ‘accredited’ training. The home has still to ensure that all staff who give medication undertake such Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 16 training. Although the inspector was advised by the acting manager that induction for such training was to take place in November 2005 the requirement is still outstanding namely that all staff who give service user’s medication must undertake accredited training as a matter of priority. All other medication records save for the above were correct at the time of the inspection. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. In addition this procedure is available in video format. The Acting Manager said that no complaints have been made to the home since the last inspection. However the inspector is concerned that the complaints procedure may not be being used as an effective tool for service users. Reponses from service user’s questionnaires, which were discussed with the acting manager, clearly showed there were concerns from service users these will be discussed at the next service users meeting. The results of these meetings should be sent to the commission. There are also policies and procedures in place regarding the protection of vulnerable adults. The home has drawn up a flow chart to ensure that all staff is aware of the action to be taken in regard to adult protection. The homes acting manager stated that the staff team are due to complete a refresher course on adult protection issues. The staff team are aware of the action they must take if they need to report an incident. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30 Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: The home is a two story building in a residential road. It is situated between Kingston and Tolworth and is close to local shops and amenities. There is a large communal lounge on the ground floor as well as a kitchen/dining room. The furniture is domestic, flame retardant, and of reasonable quality. The home does not have a lift and all service users are ambient. There has been some improvements in the décor of the home during the last year and carpets have been replaced where necessary. However some of the window frames need to be replaced and the home must submit a programme of planned refurbishment to the commission to take account of any outstanding works. The home was clean, hygienic and free from offensive odours throughout on the day of the inspection and systems are in place to control infection in accordance with relevant legislation and published professional guidance Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 19 Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 The retention of staff has improved the consistency with which service user’s needs are being met. Staff training including NVQ training needs to be addressed to ensure that staff have confidence in the work they undertake with service users and to ensure the ethos of teamwork. Such improvements are unlikely to take place until the appointment of a permanent manager who will need to monitor the training needs of all staff and ensure that supervision takes place at least six times each year. EVIDENCE: The home offers minimal training opportunities to staff at all levels within the home. Although new members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff, foundation training for one member of staff had not been completed. Foundation training should be completed within six months, notwithstanding the staff file inspected showed employment commenced in 04/05 with Foundation training commencing in 05/05 and due to finish in 09/05. Most of the said training had not been completed so the inspector was unable to verify competence of the said member of staff. However the inspector noted that the induction programmes for staff are Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 21 signed dated and kept on staff files. There was no evidence of an NVQ training programme or evidence available to show home the home will meet the standard of fifty per cent qualified to at least NVQ level 2 by the end of 2005. In addition the new acting manager needs to carry out a training needs assessment for all of the team and ensure that all staff have an individual training and development assessment profile. Criminal Records Checks are completed before a new member of staff can begin work in the home. The home has had a further change in management since the last inspection. The previous acting manager Gerald Nadal has left and the registered persons have appointed Alfred Tagoe as the new acting manager. Mr. Tagoe is experienced and qualified to manage the home, he will be submitting his application to the commission to be the permanent and registered manager of the home within the next twenty-eight days of this inspection. The new manager is committed to making numerous changes within the home including meeting many of the requirements from previous inspections. However there is a need to implement more regular supervision in line with standard 36. The registered providers acknowledged this in the ‘Action Plan’ they submitted to the commission on 5th October 2005 following the last announced inspection. It is therefore unfortunate that this standard is still not being complied with. It is suggested that the new manager undertake all the staff supervision to gain an overview of the staff. . The acting home manager is committed to sharing information with both service users and staff alike. Their need to be more awareness of service user’s rights amongst the team and a far more service user, led approach. There are at least two staff members on duty during the day plus the manager. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Although there has been an appointment of an acting manager there is a need for the appointment of a permanent manager to continue to develop the home. The residents need to see the benefits of a stable staff team and a continuity of approach this generates. However for residents and their advocates these developments need to be instigated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. EVIDENCE: The home has yet to appointment a permanent manager who has the ability to manage the project and build on the work the former acting manager has undertaken. The home has not implemented a quality assurance system that should include service user, relatives, staff and outside professional questionnaires. However the new acting manager has given questionnaires to all service users, many of these have now been completed and the acting manager is committed to Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 23 addressing the issues that have been raised. The inspector was advised that an annual audit would be completed by the end of December 2005. The acting manager completes a monthly manager’s report and this is discussed with the Directors of the home and efforts are made to meet any concerns or improve the service. The home has an annual development plan and a business plan for 2005-06, which was both seen during the course of the announced inspection. Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are now up to date, a fire risk assessment is in place although there was no evidence the fire extinguishers had been serviced or checked at least annually. The system for consultation with service users, families, stakeholders and other interested parties’ needs to be improved. Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 2 X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 1 x 3 1 1 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Acorn Lodge Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x DS0000013386.V254767.R01.S.doc Version 5.0 Page 25 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 YA3 Regulation 18(1) Requirement The registered person must ensure that all staff receive specialist training in learning disabilities and other training appropriate to the work they undertake in the care home. The registered person must ensure the service users statement of terms and conditions is revised to include all elements of standard 5.2 and the registered person must ensure that agreements with purchasing authorities make clear responsibility for the funding of day activities, including what is and is not included within existing agreements, including this in contracts with individual service users The registered person must ensure that the service users plan contains all elements of standard YA6. The Registered person must ensure that all restrictions are recorded in the Service User Plan after agreement with the purchasing authority and service DS0000013386.V254767.R01.S.doc Timescale for action 31/12/05 2 YA5 5 31/12/05 3 YA6 15 31/12/05 4 YA6 12(2) 31/12/05 Acorn Lodge Version 5.0 Page 26 5 YA17 16 6 YA20 13(2) 7 YA20 12 13 8 YA24 23(2)(b) 9 YA24 13 10 YA32 18 11 YA35.4 12 user, risk assessments completed as appropriate, and further support provided to service users to understand advocacy services available to them in the area. The registered person must ensure that storage boxes are supplied in sufficient quantity to allow secure storage of all foodstuffs thus minimising the risk of contamanation/infiltration and the registered person must ensure all ‘out of date’ foodstuffs are disposed of. The registered person must submit evidence to the CSCI, local office to show that all staff who administer medication have received accredited training The registered person must ensure all requirements and recommendations from the pharmicist’s report of 0904 are completed without further delay and make appropriate arrangements for the pharmicist to undertake an inspection of all medication issues. The registered person must send to the CSCI, local office an ongoing maintenance and development programme regarding the renewal of the fabric and decoration of the home both internally and externally. The registered person must ensure that the patio area is even and does not present a hazard. The registered person must send to the CSCI, local office an NVQ ‘Action Plan’ indicating how they plan to ensure 50 of the staff group are qualified to NVQ level 2 by end of 2005. The registered person must DS0000013386.V254767.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 30/11/05 31/12/05 Page 27 Acorn Lodge Version 5.0 12 YA35.5 18 13 YA35.6 18 14 YA36 18(2) 15 YA37 9 16 YA39 24 17 YA42 17(2) ensure that all staff undertake disability equality training, race equality and anti-racism training The registered person must ensure all staff have an individual training and development assessment profile. The registered person must ensure that a training needs assessment for all staff is carried out. The registered person must ensure that all staff at the home have formal supervision in line with standard 36 to include all elements of 36.4 The registered person must appoint a permanant manager to manage the care home and give notice to CSCI of the name of the person so appointed and ensure that the person so appointed comples the appropriate application form for registration purposes. The registered person must ensure the home has an effective quality assurance system in place to ensure the home is meeting is stated aims and objectives. This should include surveys of service users, stakeholders and other interested parties, the results of which must be sent to the CSCI, local office and the registered person must ensure that an annual audit of the home takes place at least once a year. The registered person must ensure all fire extinguishers are in working order and serviced at least annually. 31/12/05 31/12/05 31/12/05 23/11/05 31/12/05 31/12/05 Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 28 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 DS0000013386.V254767.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acorn Lodge DS0000013386.V254767.R01.S.doc Version 5.0 Page 30 - 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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