Inspection on 09/05/06 for Acorn Lodge

This inspection was carried out on 9th May 2006.

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 6 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 25/10/05

Acorn Lodge 21/06/05

Acorn Lodge 07/10/04

Acorn Lodge 20/04/04

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Edenvale

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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 Key Unannounced Inspection 9th May 2006 09:30 Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 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.V291957.R01.S.doc Version 5.1 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.V291957.R01.S.doc Version 5.1 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 Mr Alfred Nii Okine Tagoe Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 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.V291957.R01.S.doc Version 5.1 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 10th May 2006. The home was represented by the Registered Manager, Mr. Alfred Tagoe and support staff who all contributed to the inspection process. The manager is supported by Mike Hale who is the consultant to Carewatch Limited the company that manage the home. He too is very experienced and well qualified to support the manager in his day to day management of the home. 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 registered manager who will be sending an action plan to the commission as agreed at the time of the inspection. What the service does well: Service users are very much the centre of attention in the home; all of them have a programme of day care except for one who does wish to access this service. The home seeks to promote the independence of service users and ensure equality of service. All of the service users have resided at the home for some time and since the last inspection have become far more involved in the running of the home. Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of the local pharmacist for advice on medication. Staff members have access to a range of training courses to build on their skills to ensure that they are able to meet the service users assessed needs. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 7 Notwithstanding the appointment of Mr Alfred Tagoe who is now the registered manager of the home 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 have a clear vision for the future. The home does not have a deputy manager and has a very small group of core staff who are supported by bank and part-time staff. This The activity programme for service users needs to be further developed. While most of the service users are independent there is a need to increase the range and choice of activities on offer at the home. This is clearly somewhat difficult given the home only has a budget of £20 per week for all the service users’ activities which amounts to just over £2 per week for each service user. In addition the home does not provide an annual holiday for service users has laid down in Standard Fourteen. Service users would also benefit from having the use of a computer and internet connection for both educational and leisure pursuits. While the manager of the home has started to develop a training programme there is little specialist training for staff including makaton training. In addition the home does not have as a minimum 50 qualified staff to NVQ level 2. Given a requirement was made in respect of this the managing authority must send an “Action Plan” as to when they are going to meet this requirement within laid down timescales. There is also a need to ensure that all staff have received Adult Abuse training as it was evident that not all staff had. There was some concern from staff spoken to that there were not enough staff on duty at any given time, although the manager advised the inspector he was able to provide extra staff when necessary. It was noted that staff not only have to care for the service users but also cook for them and staff stated that at times this was extremely stressful and overwhelming. 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 Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 8 contacting your local CSCI office. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 9 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.V291957.R01.S.doc Version 5.1 Page 10 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, 4 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 contain all the information required under standard five thus ensuring the rights of the residents of Acorn Lodge. Staff at the home have access to a range of training programmes thus enabling them to offer an effective care programme for service users. 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. Senior staff at the home can visit the prospective service user in their current placement or own home, if appropriate. The importance of any service user coming to the home and relating to those already living at the home was clearly emphasised. A number of introductory visits are planned; this may include an activity and a meal at the home. In addition overnights stays can be arranged to ensure the service user is at ease when they come to their new home. It is clear that although this admission process takes some time it does give every chance for the new service user to settle in to their new surroundings and thus give a solid grounding to any placement. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 11 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. All of the service users at Acorn Lodge have lived at the home for some time and in discussion with the staff it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home monitors service users care plans on a monthly basis when information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The manager advised that all service users have access to an advocate has and when necessary, although the majority of service users were supported by their families and relatives. While the home has a training programme this still needs to be developed to ensure that staff have received training for the particular client group they are working with. Staff would also benefit by receiving Makaton training given one of the service user’s at the home as a communication difficulty. Contracts inspected now contained all the information as required under standard 5.2. thus ensuring service user’s rights. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 12 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 contain all the information required as per standard six. Staff at the home has all the information they require to satisfactorily meet the needs of the service users. Service users have 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 comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker who writes a monthly report on his/her service user. It is suggested that service user’s could have their own personal file written in a format they understand which they keep could and refer to. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 13 The home is beginning to be far more service user focused. Service users are encouraged to become far more involved in the home. House meetings that take place every four to six weeks are used as a communication tool to empower service users. Service users files sampled at random during this inspection all had individual risk assessments and risk management strategies. Risk assessments inspected during the course of this inspection were all found to be up to date. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice and the home provides an independent advocate where desired. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 14 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. 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 and other sporting activities. However as the home only receives £20 each week for activities for all of the service users this does somewhat restrict the range of activities on offer. In addition the home does not provide an annual holiday for service users as laid down in standard fourteen. The home has its own people carrier which makes accessing activities a great deal easier, although the inspector was advised this vehicle was used by all three of managing authority’s homes Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 15 and was usually based at another home. 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. The inspector, in discussion with the manager suggests it might be prudent for service users to have access to computers and the internet to enhance the social and educational skills. Any software would clearly need to be suitable and accessible to those with a disability. 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. Parents, relatives and friends are encouraged to visit the home whenever possible. At the last inspection some of the service users who returned questionnaires felt that were restrictions on where they could see friends. In addition there were concerns that service users were not able to develop and maintain intimate personal relationships. The manager explained these were issues for service users prior to his appointment and by issuing confidential questionnaires he was able to identify areas of concerns for service users. Both of these issues have been successfully managed. Any restriction on visitors or who a service user may visit would only be taken after discussion with parents, relatives and/or care managers and recorded on file. In addition all service users have a front door key if they wish although the manager advised some of the service users do have a propensity to loose keys – in which case they would be expected to pay for a replacement. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 16 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 well managed to ensure good health. EVIDENCE: Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. All of the staff team have now completed accredited medication training. The pharmacist visits the home on a regular basis. All requirements and recommendations from the inspection of 20th February 2006 have been complied within laid down timescales. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 17 All other medication records, including MAR sheets and service user profiles were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 18 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 an 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. The Inspector noted that any complaints appeared to centre around one particular service user and his unacceptable behaviour. The manager advised how he dealt with these situations including meeting the service user with his key worker. All complaints were managed appropriately. However the complaints book did not give details of any investigation, action taken (if any) and the outcomes. A requirement has therefore been made in this respect. 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 staff team are aware of the action they must take if they need to report an incident. The Inspector noted that not all of the staff team had undertaken adult protection training. The manager agreed to arrange such training within agreed timescales. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 19 Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 20 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 or repaired. The home now has a programme of planned maintenance which needs to take account of any outstanding works. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 21 There is also a pleasant garden at the rear of the home. Bedrooms viewed provided sufficient and suitable furniture. All areas of the premises viewed were clean and free from offensive odours. Systems are in place for controlling the spread of infection and laundry facilities were found to be reasonable. The home has thermostatic valves fitted to the bath to avoid any scalding accidents. The temperature of the water is taken and duly recorded. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 22 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 staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. The staff team have access to a wide range of training programmes which enhance their personal and professional development. EVIDENCE: The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist training courses such as that offered by BILD for staff who work with service users who have a disability 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. Given that this was highlighted at the last inspection it is Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 23 disappointing to note that most of the said training had still not been completed. However the inspector was able to verify the competence of the said member of staff as she was involved in all of the inspection process and demonstrated a wide range of knowledge. However the inspector noted that the induction programmes for staff are signed dated and kept on staff files. The manager has undertaken a training needs assessment for all of the staff team and staff now have an individual training and development assessment profile. However 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. Criminal Records Checks are completed before a new member of staff can begin work in a home and recruitment procedures are now far more robust than at the last inspection. The manager offers professional support to the support workers in addition to bank staff. He is currently responsible for the supervision of junior staff which is in now in line with the standard. The manager advised that staff meetings usually take place every four weeks. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are two staff members on duty on each shift, plus one member of staff sleeping-in. There are suitable on call arrangements in place in case of an emergency. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 24 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. The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: The manager offers support and supervision to the support workers at the home. There are good support mechanisms in place and the manager meets with the responsible individual and homes consultant to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The managing company ensure all records are in place by completing regular monthly regulation 26 reports. 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 up to date and a fire risk assessment has been completed. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 25 The residents are beginning to benefit from a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated 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. The system for consultation with service users, families, stakeholders and other interested parties has been reviewed. The quality assurance system includes service user, relatives, staff and outside professional questionnaires. The home is shortly to complete a survey for service users, care managers, families and other stakeholders. The home will need to collate the results of these surveys and ensure the outcomes will need to evidence that the results of the surveys are acted on for the benefit and wellbeing of the service users at the home. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 26 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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 Page 27 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 YA14 Regulation 5 Requirement The registered person must ensure that service users in long term placements have as part of the basic contract price the option of a seven day holiday outside of the home, which they help choose and plan. The registered person must ensure that details of any investigation, action taken and outcome are appropriately recorded following any complaint made about the service or operation of the home. The registered person must ensure all staff have received Adult Ause training. 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. (Requirement not met at 30/11/05) The registered provider must ensure that the registered manager of the home as formal supervision in line with standard 36 to include all elements of 36.4 DS0000013386.V291957.R01.S.doc Timescale for action 31/07/06 2. YA22 22. 31/07/06 3. 4. YA23 YA32 13. 18. 31/07/06 31/07/06 5. YA36 18(2) 31/07/06 Acorn Lodge Version 5.1 Page 28 6. YA39 24 The registered person must 31/07/06 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. (Requirement partly met at 31/12/05) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA12 Good Practice Recommendations It is recommended that the registered person ensure that service users have the opportunity to take up further education, distance learning and vocational, literacy and numeracy training. Acorn Lodge DS0000013386.V291957.R01.S.doc Version 5.1 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.V291957.R01.S.doc Version 5.1 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. 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