Inspection on 31/10/05 for Acorn Lodge Care Centre

This inspection was carried out on 31st 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 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 03/05/06

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 Announced Inspection 31st October 2005 10:00 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.V262611.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 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.V262611.R01.S.doc Version 5.0 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 5th May 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.V262611.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was undertaken over one days, the inspection commenced at 10.00am .Two inspectors conducted the inspection. This inspection followed up the requirements made at the unannounced visit held on 5th May 05 and the additional visits held on 12th July 05 and 29th September 05. The inspectors spoke with service users, relatives, staff and management. A tour of the environment was undertaken and samples of records were examined. One immediate requirement was made and there have been a further eighteen requirements and two recommendations made following this inspection. Verbal feedback was given at the end of the inspection. The inspectors wish to thank the managers, staff and service users for facilitating this announced inspection and actively contributing to the regulatory process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 6 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.V262611.R01.S.doc Version 5.0 Page 7 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): 1,2,3,4,5 & 6 No progress has been made to show that a proper assessment is completed prior to people moving into the home. This failure could have had serious repercussions for the health and welfare of the resident concerned. EVIDENCE: The Statement of Purpose and a Service User Guide were seen both documents are in line with the National Minimum standards. However the home is a nonsmoking environment. The inspectors acknowledge that the service user contract clearly states that the home is a smoke free building. However any restrictions in place for service users should also be included in the Statement of Purpose to ensure service users and relatives are fully informed. Acorn Lodge provide all service users with terms, conditions and contract. The document was last reviewed in October 2005 and contains all of the required information. However the document states that complaints can be made to the Commission of Social Care inspection if issues cannot be satisfactory resolved at the home. All information regarding complaints must be amended to detail Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 8 that complainants can contact the Commission for Social Care Inspection at any time. The registered manager or deputy assesses prospective new service users prior to admission. Service users and relatives are given the opportunity to visit the home prior to admission. A relative spoken to during the inspection whose mother was admitted on the day of inspection stated that they had visited the home prior to their relative’s admission. The relative was very complimentary about the staff and the smooth transfer from hospital to the home. The home undertakes a pre admission assessment to establish whether the service can meet the prospective service users needs. The files of three recently admitted service users evidenced that this assessment had taken place. However the inspectors were concerned about the lack of information they contained. The form is mainly a tick box format some of which were completed incorrectly. Through the tracking of information it was noted that the information regarding the mental health of one service user who was diagnosed with dementia was inadequate, this information was completed by tick boxes. It is regrettable that there was no evidence that the service had made no attempt to obtain a life history or note important events, hobbies or interests, similarly the details on the service users personal strengths was very limited. This information is crucial to good quality care to people with dementia. During the inspection it was evident that the service user in question was able to provide much of the information on his past experiences but staff confirmed that this discussion had not taken place. 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.V262611.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,& 10 It is the inspectors’ view that there has been limited progress on improving care plans; as such staff are unable to deliver appropriate care to service users in line with assessed health and social care needs. This potentially places service users at risk. EVIDENCE: A selection of service user plans was inspected both from the dementia and the nursing floors. Although there has been some improvement noted in the nursing service users plans, all were still found to be inadequate in describing how staff were to meet individual service users needs. This was of particular note of the service users with a diagnosis of dementia. The plans failed to address all areas of need and the actions required by staff, lacked individualised detail and subsequently failed to promote service users capacity for self-care. For example on one plan directs staff “to ensure X washes daily” but it does not detail the level of assistance needed for X to wash, nor does it reflect the assessment of X which states he is able but reluctant to attend to personal hygiene. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 10 All the care plans lacked adequate detail on service users 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 inconsistencies noted on care plans on the nursing floors, for example one service user was being monitored due to episodes of vomiting. The recordings were clear on the daily records with regards to the episodes and GP involvement however this was cross-referenced with the care plan evaluation that stated that ‘there were no concerns’. The evaluations are crucial in the development of the care plans and staff must have the ability to evaluate care appropriately. At the time of the inspection one service user had a pressure sore that had healed, a second service user had developed pressure sores after just three days in bed staff confirmed that there was no pressure relieving equipment in place. The registered manager confirmed that a tissue viability nurse saw a service user with the pressure sore much earlier than the records evidenced. A nutritional screening had been undertaken for each service user and weight changes were being monitored. Pressure relieving equipment is provided random samples were checked during the inspection. One pressure mattress was set too high for the weight of that service user. One was set for the sitting down position rather than the laying position. The service users individual plans did not indicate the correct settings for staff to follow. The registered manager explained to the inspectors that the service is currently experiencing considerable difficulties in the management of one service user’s care. A review has been undertaken and the service is waiting to be moved to a more appropriate placement. However the care plan lacked sufficient instruction to staff on how to meet the service users needs and was lacking in strategies of how staff should cope with the service users unpredictable behaviour. Again the care plan was not comprehensive and did not detail the arrangements for meeting the service users dietary, emotional, religious or communication needs and dwelt on what was a management issues for staff, such as “wandering”, personal hygiene and aggression. There was insufficient direction for staff on how to manage these issues. Additionally the service had not made any satisfactory attempts to monitor or analysis the episodes of challenging behaviours. The care plan noted the aim was to minimise triggers to the aggression but there was no attempt to identify these. It is of concern that there have been no specialist resources and support has been sought. The management of this service users care, the safety of other vulnerable service users and staff has not been well managed. The registered manager advised that there had been a review with the input from the community Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 11 psychiatric nurse and the placing authority were waiting for a vacancy in a more appropriate service. However there were no notes of the meeting that could detail how the situation is to be managed in the meantime. The risk assessments seen were basic and inadequate, they did not relate to the individual behaviours of service users and failed to identify evident risks and those risks that were identified had insufficient strategies in place to minimise harm. Untrained staff confirmed to the inspector that they undertake nursing tasks carrying out both invasive procedures and wound dressings. When staff files were checked there had been no training undertaken in these areas. On tracking these procedures it was evident that the records were found to be inadequate. The inspector observed a member of staff not to be using acceptable moving and handling techniques. The service user was effectively dragged up the bed in a move likely to cause both herself and the member of staff harm. An immediate requirement notice was issued to ensure service users are transferred safely. The inspectors observed several examples where service users privacy and dignity was not maintained. Staff need to be aware that when service users are in a state of undress then their dignity should be maintained by closing bedroom doors. The inspector was concerned about the lack of well being for some service users who were observed frequently during the day attempting unsuccessfully to leave the dementia unit. Service users movements are restricted with coded door locks to ensure they cannot leave the unit independently. It is of concern that there has not been a risk assessment involving individual service users and their family or advocates in regard to this violation of serious infringement of service users human rights. Spot checks were undertaken on medication. The inspector acknowledges that there has been a great improvement noted. One error was found in a box of sachets, where one extra was noted. However the inspector acknowledges that this was a supply of new medication that had been received by the home and should have contained 28 however 29 were counted. Staff must ensure that all medication is checked as correct on receipt into the home. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 12 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, 14 &15 Some work has been done to introduce activities into the home, however activities are still limited which restricts choice to service users particularly those suffering from dementia. EVIDENCE: There is a full time activities coordinator who provides both group and one to one activities with service users. On discussion with the co coordinator the inspector was satisfied that work is commencing to look at individual needs. However as previously stated there was no evidence that the service has made no attempt to obtain a life history or note important events, hobbies or interests, on admission which should be recorded on service user plans. Such information would inform the coordinators work in the development of the activities programme to maximise service users capacity to exercise personal autonomy and choice. The inspector acknowledges that these issues have been discussed with in relatives meeting held in September 05. Minutes seen indicated that more external outings were to be arranged and relatives to be encouraged to attend. Additionally relatives were asked to bring photographs, mementoes for the service users that could be used in reminiscence and life story work. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 13 During the inspection it was evident one service user was able to provide the inspector with much of the information on his past experiences but staff confirmed that this discussion had not taken place. Visitors were observed being able to spend time with the service users and were very relaxed in the home. Visitors spoken to during the inspection stated that they were made to feel welcome. Observations made during the inspection confirmed this. As previously stated service users movements are 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. Most service users finances are either managed by the home or the service users families. Finances managed by the home were checked and deemed correct. The inspector spoke with the kitchen staff; at present the menus are on a fourweek cycle. The menus were seen and these now include culturally appropriate choices. The current situation is that the cook pre prepares the evening meal however the inspector was informed that as the home was becoming occupied that the kitchen staff with work shifts in the near future. On inspection the kitchens were clean and organised. The inspector saw the food storage facilities; fresh, frozen and dry stocks were appropriately stored. Inspection of the food storage areas found that bread stocks remain extremely close to the ‘best by’ date. Staff stated that this is monitored and that the bread in question was to be used in cooking. Staff maintain relevant daily checks on the temperatures of the fridge and freezers, records were seen. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 14 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, &18 Clear guidance is available for staff to respond to allegations of abuse effectively and efficiently in order that service users are protected. 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. As previously stated this must be the information that is added to the service users contract. 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. Complaints are logged on each of the floors. Through discussion with the registered manager it appears that relevant procedures are followed and complaints are dealt with appropriately within stated timescales. There are procedures in place for dealing with allegations of abuse. Adult Protection guidelines were seen which noted that the flow chart, which has been amended, to highlight that the Commission must be informed of any allegation made. The registered manager has updated the financial systems. Service users finances were seen which were being recorded accurately and were deemed correct. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22, 23,24,25 & 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. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 16 One the day of the inspection one of the lifts was out of order however it had been reported and was to be maintained during the day of inspection. 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 individual rooms seen had been personalised and were comfortable. All of the communal areas and service users bedrooms were of adequate cleanliness and hygiene. There is a separate laundry facility, which was clean and tidy. 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.V262611.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 & 30 Recruitment safeguards are now in place, however it was of considerable concern that examples of ability and quality of staffing were found to be lacking. This not only compromises the overall provision of individulised care, but also presents risk to service users. EVIDENCE: Rotas indicated that staffing levels are satisfactory with regard to staff to service user ratios however given the issues in this report there are concerns about the dementia floor where service users needs are high and as such staffing may need to be monitored and revised. It was noted that staff that were employed with student visa were at times working in excess of the allowed hours. The registered manager must monitor any agreed extra hours. Much of the inspection was spent observing staff, and service users; concern was raised with regards to the skills of some staff when assisting service users. As previously stated in this report the inspector observed a member of staff not to be using acceptable moving and handling techniques. An immediate requirement was issued which management addressed following the inspection. Additionally untrained staff confirmed to the inspector that they undertake nursing tasks carrying out both invasive procedures and wound dressings. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 18 When staff files were checked there had been no training undertaken in these areas. During the inspection one service user put her head in here hands and told the inspector “this place with all the noise is driving me crazy”. A stereo blared out music for most of the day at a level that was not conducive to any social interaction. Staff should be aware that when people need to concentrate on a skill such as feeding themselves the environment should be calm and peaceful. Apart form the unsettling experience of excessively loud music playing service users would not be able to hear verbal prompts from staff. The inspectors did observe some sensitive interaction from several staff however there were also several examples of poor practice, which led the inspectors to be concerned about adequacy of staff’s knowledge and skills in providing a service to people particularly those suffering with dementia. Additionally the relative’s questionnaires provided positive feedback with regards to some staff. One commented ‘ the two seniors are excellent and so are the workers’. Staff files indicated that much training has been undertaken and through discussion with the registered manager the inspector is satisfied that this is on going. However the concerns in this report highlights the need to evaluate staff competencies following training. The registered manager has reviewed and updated the staff files. 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 acknowledges that much work has been done in this area since the previous inspection. The inspector was informed that twenty of the current staff team have completed a Numeracy and Literacy course, and were to undertake the National Vocational Qualification level 2 in care in November 2005. The inspector is satisfied that the organisation is endeavouring to achieve 50 of staff trained to NVQ Level 2.This will be inspected full at the next statutory inspection Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36,37 & 38. Much work has been undertaken since the previous inspection however given the content of the report there are serious concerns about how the quality of care is being monitored. EVIDENCE: The registered manager has undertaken much work since the previous inspection. This is of particular note regarding recruitment checks and medication. Through case tracking inconsistencies with recording were noted and changes in assessed care needs were not transferred to other documentation such as individual care plans and risk assessments. Records regarding accidents were seen however the quality of the information was poor, one did not indicate whether a service user or staff member had Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 20 been injured, one was incomplete. Through the cross tracking of information on service users file it was noted that not all accidents are recorded. Records regarding incidents were seen however as stated this information did not trigger the care plan being updated or a risk assessment being developed. The registered manager stated that the clinical supervision is undertaken but not recorded. There was also no recorded supervision for care staff. This matter must be addressed as a matter of urgency. The service users’ finances and petty cash were seen which were being recorded accurately and were deemed correct. However concern was raised, as some residents had no monies deposited and had been placed for some months. Staff indicated that toiletries would be purchased for the service users however additional items were not. During this inspection concerns were noted with the skills and competicies of particular members of staff and as such requirments have been made. Given the content and concerns raised in this report the registered manager must maintain a system for monitoring and improving the quality of care provided in the care home as a matter if urgency. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 1 2 2 Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 22 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 OP2 Regulation 22.7 Requirement The registered manager must amend the complaints information within the contract to detail that complainants can contact the Commission for Social Care Inspection at any time. The registered manager must ensure that service users are admitted only after consideration of a full and accurate preadmission assessment, which should be retained and made available for inspection. (Timescale of 30/6/05 not met) The registered manager must be able to demonstrate that service users assessed needs are being met by the home, particularly those of service users who suffer from dementia. The registered manager must ensure that service users individual plans accurately reflect their needs. The registered manager must ensure that all service users have plans of care which show DS0000062717.V262611.R01.S.doc Timescale for action 31/12/05 2 OP3 14.2 31/12/05 3 OP4 12 &14 31/12/05 4 OP7 15.1 31/12/05 5 OP7 15.2(b) 31/12/05 Acorn Lodge Care Centre Version 5.0 Page 23 6 OP8 12.1 7 OP14OP8 13.4 8 OP8 23.2 (c)12.1(a) 9 OP8 13.1(a) 10 OP38OP8 13.5 11 OP9 13.2 12 OP10 12.4 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 incidence of pressure sores , their treatment and outcome are recorded in the service users individual plan of care and reviewed on a continuing basis. 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 clinical equipment is appropriately used and set for individual service users as per the manufacturers instructions(Timescale of 30/6/05 not met) 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. The registered manager must implement a system within 24 hours that ensures only staff who are trained appropratly undertake moving and handling of service users. The registered manager must ensure that all mediaction is received and recorded accuractly. The registered manager must ensure that the privacy dignity of all service users is preserved at all times. DS0000062717.V262611.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 01/11/05 31/12/05 15/12/05 Acorn Lodge Care Centre Version 5.0 Page 24 13 OP12 16.2(m) (n) 14 OP27 15 OP30 16 OP30 17 OP33 18 OP36 19 OP38OP37 The registered manager must ensure that service users are given sufficient choice and appropriate activities to meet their needs particularly those suffering from dementia. 18.1(a) The registered manager must ensure that at all times suitably qualified ,competent and experianced staff are working in the care home in such numbers that are approprate for the health and welfare of service users. 18.1(c) (i) The registered manager must undertake a training needs anayalis of all staff and use this to develop and individual training and development plan to equip staff with the skills and knowledge to meet service users needs appropratly. 18.1(c ) The registered manager must ensure that staff are adequatly trianed in meeting the needs of service users with dementia.(Timescale 31/08/05 not met) 24.1(b) The registered manager must maintain a system for improving the quality of care provided in the care home. 18.1(c)(ii) The registered manager must ensure that all staff in the home are apprpriatly supervisied at least six times a year.Supervision records must be maintained. 17.1.2.3 The registered manager must ensure that all records required by regulation 17 are maintained accuratly and upto date. 31/12/05 15/12/05 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP27 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 be implemented to ensure that staff only work hours permitted by visa restrictions. Acorn Lodge Care Centre DS0000062717.V262611.R01.S.doc Version 5.0 Page 26 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.V262611.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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