Inspection on 03/05/06 for Acorn Lodge Care Centre

This inspection was carried out on 3rd 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 but made no statutory requirements on the home.

Other inspections for this house

Acorn Lodge Care Centre 20/10/08

Acorn Lodge Care Centre 30/10/06

Acorn Lodge Care Centre 31/10/05

Acorn Lodge Care Centre 05/05/05

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Acorn Lodge Care Centre 15 Atherden Road Hackney London E5 0QP Lead Inspector Kristen Judd Unannounced Inspection 3rd May 2006 07:50 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 Care Centre DS0000062717.V292204.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 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 Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Acorn Lodge Care Centre Address 15 Atherden Road Hackney London E5 0QP 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) 020 8533 9555 Acorn Lodge Ltd Diane Jureidin Care Home 98 Category(ies) of Dementia (0), Dementia - over 65 years of age registration, with number (0), Old age, not falling within any other of places category (0), Physical disability (0), Physical disability over 65 years of age (0) Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of beds 98 to be used flexibly amongst the various categories. With the following categories: Old Age, not falling within any other category (OP) either sex Residents 50 years of age with a diagnosis of dementia (DE) either sex Residents 65 years of age with a diagnosis of dementia DE (E) either sex Residents 50 years of age (PD) either sex Residents 65 years of age PD (E) either sex One named service user to be admitted in the Physical Disability Category under the age of 50 One named service user to be admitted in the Physical Disability Category below the age of 50 31st October 2005 2. Date of last inspection Brief Description of the Service: Acorn Lodge Care Home is a 98 care home situated in a quite residential area of the London Borough of Hackney. The home is within easy access of local transport and community facilities. The home was opened in 2005 and is a purpose-built four-storey building. All the bedrooms are single with en-suite facilities. En-suite facilities consist of a toilet and wash hand basin and are accessible to wheelchair users. There is a passenger lift to all floors. The home is registered to take service users who sufferer from dementia. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced the inspection at 7.50 am. This inspection report followed up the requirements from an additional visit conducted on 12th January 2006. The inspector spoke with service users, relatives, staff and the registered manager during the inspection. A tour of the environment was undertaken and samples of records were examined. There have been 14 requirements and 6 recommendations made following this inspection. An enforcement notice will be serviced regarding medication. Verbal feedback was given at the end of the inspection. It was noted that the management continue to receive the verbal findings positively, and respond positively to resolve and further develop those areas where action is now required. The inspector wishes to thank the management team, staff and service users for facilitating this announced inspection and actively contributing to the regulatory process. A feed back card was left for completion. What the service does well: What has improved since the last inspection? What they could do better: Medication was poor and as such enforcement action will now be taken. supervision of staff is poor not all staff have received a supervision session and there are currently no records maintained. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 6 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 Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 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 Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 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): 1,2,3 & 4 Evidence seen suggests that appropriate pre admission assessments are being completed to ensure that service users needs can be met within the placement. EVIDENCE: The Statement of Purpose and a Service User Guide were seen both documents are in line with the National Minimum standards. The documents were reviewed in April 2006 and now include information with regard to the home being a smoke free building. Acorn Lodge provides all service users with terms, conditions and contract. The document contains relevant details for example, the room to be occupied by service users; the services covered by the fees; the arrangements for paying fees; any services over and above those included in the fees, the rights and obligation of the service user and the provider, and the terms and conditions of occupancy, including any period of notice. The document has been updated and now clearly states that complainant can be made ant any time to the Commission of Social Care inspection. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 9 The registered manager or deputy assess prospective new service users prior to admission to establish whether the service can meet the prospective service users needs. There has clearly been an improvement in the pre admission assessments. Through the discussion with the registered manager the inspector was satisfied that service users are only accepted if deemed an appropriate placement. However attention must be taken with regard to signing and dating of all documentation. Service users and relatives are given the opportunity to visit the home prior to admission. There was evidence that some service user files have been re formatted since the previous inspection and indicated basic information and admission form, copies of the local authority statement of need and care plan in addition to the home pre admission assessment. The home does not provide intermediate care. If, at a future date, the registered provider should wish to provide such care, consideration would need to be given to staffing levels, appropriate staff training and the provision of dedicated space for this purpose. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 10 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 &10 Further progress has been made with regard to the service users care plans however all key needs must be recorded to ensure that all care needs will be met. It was the inspectors view was that medication was not being accurately administered; this must be addressed as a matter of urgency. Staff must be fully trained and competent before being permitted to administer medication. EVIDENCE: A selection of service user plans was inspected both from the dementia and the nursing floors. There has been some improvement noted since the previous inspection. Service user files showed evidence of management completing audits and highlighting missing information or aspects of the service users needs that required care planning. However it was also noted that following audit the tasks had not always been completed. For example one audit stated that the service user required a communication care plan, which was, implemented however there was also a requirement for further information to be added to the care plan regarding the service users pressure ulcer, this remained outstanding. It is recommended that a system be implemented to check that actions are completed in a timely fashion. Service users with a diagnosis of dementia have a separate care plan that covers the problems, possible difficulties and action to be taken. This is a set care plan of a tick box format. As a result the care plans for service users with Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 11 a diagnosis of dementia are all the same. As stated in the previous inspection report adequate detail on service users individual strengths and abilities, in providing a service to people with dementia it is crucial that actions of staff build upon the existing strengths of service users. There were some inconsistencies noted on care plans on the nursing floors, for example one service user care plan was updated on 21/3/06 with regard to pressure care and clearly stated two hour turns. Documentation however reflected four hourly turns were in place. The inspector spoke with staff who confirmed that the turns were four hourly and information from the tissue viability nurse was seen to confirmed this dated 22/3/06. The care plan however had not been updated. The registered manager must ensure that incidence of pressure sores; their treatment and outcome are recorded accurately in the service users individual plan of care. Daily records were examined. The inspector noted that one-service user had erratic sleep patterns. At times the service user walks around the corridors until the early hours of the morning. There were also records that indicated that the service user would refuse to sleep in his room. There was no evidence of what strategies were in place to guide staff at these times .The service has not made any satisfactory attempts to monitor or review the service users behaviour. Additionally the same service user was refusing meals as often is asleep during meal times. The inspector was also very concerned as the records indicated that the service user had a tendency to eat cornflakes when awake and little else. There was no evaluation of these records in place. No care plan had been implemented regarding these concerns. The registered manager must ensure that service users individual plans accurately reflect their needs The inspector cross-referenced additional documentation and noted that the service user had lost 6kg in three months. However the ‘Waterlow assessment’ stated that the service users appetite was average. The nutritional screening tool stated ‘eats snacks rather than meals’ however the inspector’s evaluation was that the service user clearly misses meals. Another service user file provided clear direction for staff to follow regarding the service users blood sugar level. Documentation states ‘if below 4 offer drink with glucose powder and check every 15 minutes until between 4.5-5’, on 1/5/96 the service users level was recorded as 3.8 however there was no evidence of the action taken. The registered manager must ensure that all records are maintained accurately and appropriate action be taken if needed. There has been an improvement noted in the nursing service users plans, but they are still found to be lacking in describing how staff were to meet individual service users needs. For example one service user care plan indicated that the service user had suffered pressure sores, which had healed; the care plan had been crossed through. However there was no care plan Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 12 implemented for the prevention of pressure sores. The service users file clearly indicated that this was a need. Daily records on 2/5/06 indicated a red areas being noted by staff but no action noted by staff. Another service user care plan indicated that the service user had an indwelling catheter and the evaluation stated that this has been removed in August 05 however the continence care plan had not been updated. The inspector noted that there is still concerns regarding the lack of risk assessments in place and some are still deemed inadequate. For example the new format indicates whether there is a risk and notes that each potential risk identified had to have a full corresponding risk assessment in place. Through the tracking of documentation this was not always the case. Additional information was case tracked, one service user who assessment clearly stated that there were problems with swallowing however the risk of choking had not been highlighted as a potential risk. Another service user was continually refusing medication however this situation had not been risk assessed. Service users movements are restricted with coded door locks to ensure they cannot leave the unit independently. It is still lacking in evidence of clear risk assessment involving individual service users and their family or advocates in regard to this violation of serious infringement of service users human rights. Pressure relieving equipment is provided random samples were checked during the inspection, there were no concerns. Random medication checks were conducted on all of the floors. One service had no prescribed ‘Senna’ medication available for seven days. A medication check was conducted for one service user who was prescribed two different dosages of ‘Warfarin’. One of the doses had not been given. As previously highlighted drugs such as ‘Warfarin’ are prescribed at set doses that will seriously affect the wellbeing of the service user if not administered in accordance with prescription. Another check was conducted for one service user who was prescribed ‘paracetomol’, the medication stocks were deemed incorrect. Staff indicated that at times the medication was taken from the ‘homely medication stock’ rather than the service users own prescribed stock. A further twelve random checks over three floors was conducted eight of which were deemed incorrect. Since there have been repeated failures to adhere to appropriate procedures for the administration of medication, the Commission will be taking enforcement action to secure compliance for the health and wellbeing of service users. The Commission will now take enforcement action to ensure that satisfactory improvement is made for the wellbeing and protection of service users. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 13 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 Some work has been done to introduce activities into the home, however activities are still limited which restricts choice to service users. EVIDENCE: Service users are encouraged to bring their own possessions on admission if they wish. The inspector viewed a random selection of service users bedrooms and they all contained personal possessions including toiletries, pictures, photographs and ornaments. There is an activities coordinator now in post who focuses on the ground floor each morning and the first floor each afternoon. Staff who work on the dementia floor coordinate the activities for the floor. On arrival to the dementia floor the staff were discussing the work allocation for the day, one staff member took responsibility for the activities for the day. Clearly work has been done in this area however this is a large home and staff and one person on a floor of 31 service users will provide limited support for individualised activities. The inspector was present on the dementia floor several times throughout the inspection. The floor appeared calm and service users seemed settled into their daily routine. However as previously stated service users movements are Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 14 restricted with coded door locks on all floors of the home to ensure they cannot leave the unit independently. Service users files must evidence relevant and appropriate risk assessments to minimise risk without imposing inappropriate restrictions on the service users. During the inspection service users were escorted to the garden in small groups with staff. However limited evidence could be seen in the daily diary notes to indicate that service users are supported to go on trips, outings and to use other facilities in the community. The quality of the care notes must be improved to fully demonstrate that service users are supported to maintain their interests. The inspector had the opportunity to speak with a relative who was complimentary of the staff and the care provided to his father. The relative commented that they were always made to feel welcome and had no concerns. Most service users finances are either managed by the home or the service users families. The inspector spoke with the kitchen staff; at present the menus are on a fourweek cycle. Menus seen were found to be balanced and interesting, offering culturally appropriate meals on occasions. Service users spoken to during the inspection commented that the food was good. Most foods are home made including cakes for afternoon tea. On inspection the kitchens were clean and well organised. The inspector saw the food storage facilities; fresh, frozen and dry stocks were appropriately stored. Staff maintain relevant daily checks on the temperatures of the fridge and freezers, records were seen. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 15 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 & 18 All complaints must be dealt with in line with procedure and outcomes clearly recorded so that service users, relatives and others will be confident that all complaints are listen to and taken seriously. EVIDENCE: The complaints policy and procedure includes the information that complainants can approach the Commission without going through the formal complaint procedure of the home. The contact details given for the Commission are correctly given. The registered manager investigates complaints and concerns that service users, relatives or staff may have. Through discussion with the registered manager it appears that relevant procedures are followed and formal complaints are dealt with appropriately within stated timescales. Records of complaints were seen which clearly recorded outcomes. However through discussion it was apparent that verbal/informal complaints although dealt with are not recorded. The registered manager stated that these tend to be minor concerns that can be dealt with swiftly. The registered manager must set up a system to record and deal with these complaints. The registered manager informed the inspector that service users had not been entered onto the electoral role and therefore did not vote in the recent elections. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 16 There are procedures in place for dealing with allegations of abuse. The registered manager is fully aware of her responsibilities to inform the Commission. Following a recent concern the inspector was kept fully informed by the registered manager and correct procedures were followed. The inspector spoke with the administrators about the financial systems in place. The home system seems robust however there are some concerns regarding service users monies which will be addressed later in this report. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 17 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): 19 & 26 It is the view of the inspectors that the environment is suitable for this service provision .The home was found to be clean and hygienic during the inspection. EVIDENCE: The location and lay out of the home is suitable to meet the service users needs. A tour of the premises was conducted. The home is situated in a quite residential area of Hackney is within easy access of transport links and the local community. The home is within walking distance of some local amenities; there is a small garden area surrounding the home. There is parking available. The home is a purpose built premises, on four floors. All of the bedrooms are single, having en-suite facilities. There are main communal areas on each floor and small satellite kitchens. The staff provide snacks and drinks from small satellite kitchens, which are on each floor. Random selections of bedrooms were seen; all of which had been personalised and were comfortable. It was noted that room 83 had a badly stained carpet; Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 18 the registered manager once aware requested that the carpet was cleaned on the day of inspection. It is recommended that as staff complete a handover in the service users individual rooms that any such issues are raised at this time and reported to the domestics on a daily basis. There was evidence of appropriate aids and adaptations available for service users including mobility aids and hoists with accompanying slings. The bathrooms have suitable equipment to meet the need of service users. There is a call system throughout the home. Specialist equipment is available for transferring service users. All of the communal areas and service users bedrooms were of adequate cleanliness. It was noted that on the dementia floor there was a smell of urine. A new system was being installed on the day of inspection, which was to neutralise the odours. The inspector acknowledges that this did improve during the day. The registered manager stated that she would monitor how the system works over the coming weeks. Domestic staff are now allocated to each floor, which allows for responsibility to be clear this support is provided seven days a week. There is additional support between 5-8.00pm each day in the home from one domestic that covers all areas of the home. This has clearly had a positive impact on the home. There is a separate laundry facility, which was clean and tidy on the day of inspection. The lint is removed from the dyers daily, records are maintained which were seen. The staff use degradable bags for soiled items, to limit infection spreading. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 19 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): 27,28,29 &30 Staff have completed much training since the previous inspection however all mandatory training must be up to date to ensure that service users are not put at undue risk. EVIDENCE: Rotas indicated that staffing levels are satisfactory with regard to staff to service user ratios. All staff that work on the second floor have completed a two-day dementia course. The training programme for the year includes manual handling, fire safety, tissue viability, and infection control and food hygiene. Additionally dementia and Abuse training are ongoing throughout the year. A training need analysis has been completed and training needs highlighted to cover subjects such as challenging behaviour, care plans, medication, COSHH and leg ulcers. Training is provided both internally as well as some external provision such as continence training, nutrition in the elderly and death and bereavement. One staff member had been employed for four weeks and had no understanding of Adult Protection at all. The staff member stated that he was in the process of completing an induction programme but was unaware of any training planned for him. Some staff are still to undertake mandatory training such as Basic Food Hygiene, First Aid and Fire training. The registered manager has clearly worked Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 20 hard in this area although it must be a priority that all staff complete all mandatory training. The registered manager has set up meetings for different staff groups, at the time of inspection meeting had been held for the domestics, the ground and first floors. Minutes of these meetings are brief and it is recommended that staff meeting be recorded accurately. A random selection of staff files were examined. Evidence indicated that the home had undertaken all the necessary recruitment checks to ensure protection of residents. Criminal Records Bureau checks were complete. The inspector was informed that fifteen staff members are due to finish the National Vocational Qualification Level 2(NVQL) in June 2006. Another ten to fifteen staff will commence in August 2006. All staff are completing TOPSS 1-5 before commencing the NVQL course. Staff with limited English are also attending literacy and numarcy courses. The inspector is satisfied that the organisation is endeavouring to achieve 50 of staff trained to NVQ Level 2.This standard will be fully assessed at the next inspection. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 21 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): 31, 33 35 & 38 Much work has been undertaken since the previous inspection however given the content of this report there remain serious concerns with regard to medication and the lack of recorded supervision. EVIDENCE: Through interviewing the registered manager, the inspector was satisfied that the home is managed in an open and positive manner. The registered manager has responded well to the previous inspection and there has been much focus on developing systems within the home. However this work must continue. For example ensuring that the audits completed on service users care plans which is deemed good practice are actioned and checked. The inspector was informed that supervision with staff had commenced, and a schedule developed however there were no records of supervision to examine. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 22 On discussion with the registered manager she stated that such sessions were not being recorded. Supervision sessions must be recorded to evidence how management are to evaluate practice and identify areas of training and further development of individual staff. A relatives meeting was held in January 2006 although this was not well attended however relevant subjects were discussed. During the inspection both service users and staff made positive comments however the findings of the inspection still raise some concerns. The annual development plan indicates that there will be on going audit with regard to the care plans and medication. As previously stated in this report there will also need to be follow up to ensure any actions required are completed efficiently. Service users finances were seen; one was slightly out at the time of inspection. Through the discussion with the administrator it was not clear where the error was. Another service users had in excess of £700.00 in their account, staff were unable to clarify where the money was held, whether it was a central account or the service users individual account. It was noted that not all of the required Health and Safety checks had been completed annually. The portable appliance test (PAT) was scheduled for 4/5/06. The following outstanding checks were scheduled for week beginning 8/5/06 • • • • Gas Fire Alarm Nurse Call System Legionellas The registered manager must ensure that all checks are completed in a timely fashion. Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 23 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 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 1 x 2 Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 24 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 OP7 Regulation 15.1 Requirement The registered manager must ensure that service users individual plans accurately reflect their needs. (Timescale 31/12/05 not met) The registered manager must ensure that all service users have plans of care which show how each assessed need is met/managed and that the care plans are reviewed on a monthly basis and/or when the needs of the service user change. (Timescale of 30/6/05 not met) The registered manager must ensure that all risks are assessed and risk assessments are updated. The registered manager must ensure that incidence of pressure sores, their treatment and outcome are recorded in the service users individual plan of care and reviewed on a continuing basis. (Timescale of 31/12/05 not met) The registered manager must ensure that all records are maintained accurately and DS0000062717.V292204.R01.S.doc Timescale for action 31/07/06 2 OP7 15.2(b) 31/07/06 3 OP7 13.4 31/07/06 4 OP8 12.1 31/07/06 5 OP8 17 31/07/06 Acorn Lodge Care Centre Version 5.1 Page 25 6 OP8 13.1(a) 7 OP13 16.2 8 OP14 13.4 9 OP16 22.3 10 11 OP30 OP35 18.1(c ) 25.1 12 OP36 18.1(c)(ii) 14 OP37 17 appropriate action be taken if needed. (Timescale of 31/03/06) The registered manager must ensure that service users receive where necessary treatment, advice from health care professionals, such input must be recorded on service users files. (Timescale 31/12/05 not met) The registered manager must ensure that the quality of the care notes be improved to fully demonstrate that service users are supported to maintain their interests, contact with family and the local community. The registered manager must ensure that appropriate risk assessments are in place to minimise risk without imposing inappropriate restrictions on the service users. (Timescale of 30/6/05 not met) The registered manager must ensure that any form of complaint is recorded and dealt with in line with procedure. The registered manager must endure that all staff complete mandatory training The registered manager must complete an audit on service users monies and forward a confirmation of the where service users monies are held to the Commission for Social Care inspection. The registered manager must ensure that all staff in the home are appropriately supervised at least six times a year. Supervision records must be maintained.(Timescale of 28/02/06 not met) The registered manager must ensure that all records required by regulation 17 are dated and DS0000062717.V292204.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 31/08/06 31/07/06 31/07/06 15/07/06 Acorn Lodge Care Centre Version 5.1 Page 26 14 OP38 23.2 signed appropriately. The registered manager must ensure that all health and Safety checks are up to date and copies of certificates forwarded to the Commission for Social Care Inspection. 15/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP7 OP12 Good Practice Recommendations It recommended that the Statement of Purpose is updated to include any restrictions for service users that are in place. It is recommended that a system is implemented to check that the actions noted following audits of files are completed are completed in a timely fashion. The registered manager should monitor was activities taken place and how many service users are involved to evaluate and allow further development of activities in the home. This is partially importance for the second floor. The registered manager should ensure that all service users are entered onto the electoral role. It is recommended that any issues noted in service users rooms at handover be reported to the domestic team on a daily basis. It is recommended that the development plan is adhered and further checks on outcomes are made. 4. 5. 6. OP17 OP24 OP33 Acorn Lodge Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Care Centre DS0000062717.V292204.R01.S.doc Version 5.1 Page 28 - 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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