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

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 31/10/05

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 5 & 6th May 2005 at 11.30am th 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 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 G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 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 nileshlukka@lukkahomes.co.uk 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 G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th March 2005 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. The home is registered to take service users who sufferer from dementia. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was undertaken over two days, the inspection commenced at 11.30 on day one. Two inspectors conducted the inspection. This inspection followed up the requirements made at the additional visit conducted on 20th April 2005. The inspectors spoke with service users, relatives, staff, the deputy manager and registered manager during the inspection. A tour of the environment was undertaken and samples of records were examined. The occupancy level at the time of inspection was 38 service users. There have been twenty requirements made following this inspection. This inspection focused mainly on service users care, medication, staff files and environment. Verbal feedback was given at the end of the inspection. It was noted that both the deputy and registered manager received the verbal findings positively, and responded positively to resolve and further develop those areas where action is now required. The inspectors wish to thank the managers, staff and service users for facilitating this unannounced 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: Improvements have been made regarding the administration of medication however there are continued concerns regarding inaccurate recording of medication identified. Assessment and care planning was lacking, the service must ensure that service users needs are clearly documented to ensure that these needs can be met. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 standard(s) 3,4&5 Information regarding service users must be accurate to enable staff to deliver appropriate care to service users in line with assessed health and social care needs. EVIDENCE: This is a newly registered home and as such there are new admissions on a weekly basis. Service users and relatives are given the opportunity to visit the home prior to admission. The deputy manager and registered manager assess prospective new service users prior to admission. Records seen showed that a pre-admission assessment is completed, which is followed by the resident assessment. In addition on admission there is a basic information form for completion. However forms were not always fully completed, in particular relevant information such as the weight of service users, important life events and social background. Such information will assist staff in meeting the needs of the service users. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 9 The assessments should be used to develop the service users individual plans; this must include all the medical information of the service users that requires medical assistance/monitoring. Some of the service users individual plans showed evidence of their needs and preferences. One the first day of inspection a new service user was admitted, staff were observed settling the service user in and recording additional information. However concerns were raised as the television was on and the staff member was not interacting with the service user or trying to involve them in the process. Relatives spoken to during the inspection stated that they had visited the home prior to their relative’s admission and were able to choose rooms. Due to some recent changes some of the service users are being moved to other floors however relatives had been involved in the discussions and were being given the opportunity to choose rooms. Service users are encouraged to visit the home prior to admission dependent on their ability. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 standard(s) 7,8&9 Gaps in the assessed needs of service users care plan indicate that service users needs were not being fully met. These shortfalls have the potential to place service users at risk. EVIDENCE: The care plans described service users health and social needs. However they were not consistent to provide staff with the information needed to meet service users needs. Concern was raised, as care plans appeared similar, particularly on the residential floor. Through the tracking of records one service users care plan indicated risk of falls however the service user in question was fully mobile without concern. On discussion with staff it was confirmed that the basic care plan with three identified needs, wandering, risk of falls and sleeping pattern were the same for all service users. Through the tracking of information there was little evidence to show that information contained in the assessment had been transferred to the individual care plans. Such information must be used to ensure that the correct care is provided to meet service users needs. Two service users required follow up swabs to be taken so that their conditions could be monitored though these had not been done. One service users physical needs indicated a ‘head rest to be used only in the evenings’, however evidence was seen of this being used Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 11 throughout the day. However this file did contain good recording with regard to turning records. There was evidence that care plans were reviewed monthly, however there was no detail and no evidence that the care that the service users had received had been evaluated. There was a lack of risk assessments on moving and handling, health issues (when refusing medication, or conditions that could be transmitted to other service users or staff) and mental health, which could potentially put staff and service users safety and well being at risk. On day one of the inspection the inspectors observed one service users lunch was still untouched at 3.30pm. On inspection of daily recording staff had entered that lunch had been taken. On further tracking of care it was noted that the service user required assistance with feeding. In addition pressure relieving equipment was provided which could not be assessed as being appropriately set as the service user had not been weighed since admission (one month), in addition the service user was a non insulin dependent diabetic. The nurse spoken to stated that carers had indicated that the service user had eaten and so she had made the entry on the daily records. The inspector highlighted the concern regarding the overall care being received by this service user. Additional information was provided including a dependency scale however the inspector noted that there were inaccuracies in calculations which meant that a service user was variably described as from low to medium dependency. There was no indication that this information was transferred to the care plan or evaluated even though there was a clear change in the service users need. Daily recording highlighted when service users were seen by relevant health professionals, however the staff should ensure that recordings are made on correct formats with the health professionals indicating clear directions as to the care provision required. This is of particular importance with one-off medications being prescribed. Pressure relieving equipment is provided, staff spoken to during the inspection were aware of what equipment service users needed and how to set the equipment taking into account service users weight. However some of the service users did not have weights recorded and so it could not be determined as to whether the equipment was appropriately set. Policies and procedures were available for guidance on the administration of medication. Medication was randomly inspected on three of the occupied floors. The inspectors were informed that a Monitored Dosage System would be in place in the coming weeks, however much of the prescribed medication Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 12 was still presented in generic packaging. Sharps containers were required for each of the floors. Medication Administration Records ( MAR ) sheets were seen, several gaps in recording were noted. For one service user over a period of twelve days nine gaps were noted in the recording. Two service users did not have prescribed medication available for several days. This means that service users had been left without medication as provided by the medical practitioner. This is a serious lapse in the duty of care. One service user - an insulin controlled diabetic - had ‘not required’ on MAR sheets for four separate days however staff had not checked sugar levels to confirm whether the service user required the medication. The service user was refusing to have sugar levels tested more than once a month. Staff spoken to were aware of observations that would be made to ensure that the service user was well however there was no clear guidance in place or information on the service users individual care plan. In addition this situation must be supported by a comprehensive risk assessment. The residential floor were to have completed daily medication audits – a response to previous requirements made by the Commission, however it was evident that this check was not being undertaken accurately or regularly. One service users medication had a discrepancy of fifteen tablets. It was noted that on the nursing floor the stock records were accurate. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 standard(s) 12,13 &15 Provision of meals is well managed, although work is needed to provide more cultural appropriate options to enable service users to have choice and meet their cultural needs. EVIDENCE: There is a full time activities co coordinator who provided both group and one to one activities with service users. Each service user had in place a social activities care plan and daily recording, which indicated if activities had been undertaken. There was evidence on the documentation that specific interests had been taken into account in particular on the residential floor. Relatives spoken to over the two days indicated that they were made to feel welcome and were able to make themselves a drink in the satellite kitchen. Visitors were observed being able to spend time and were very relaxed in the home. During the tea being served on day one the inspector asked staff about dietary needs of a service user, the inspector was shown what was being provided but staff were unable to indicate that the service user in question followed an Halal diet. The inspectors discussed with one relative cultural meals, she stated that they had not been any provision since her mother was admitted, however was Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 14 complimentary of the food provided and stated that her mother appeared to like the meals. The inspector was also present on day two during the service of breakfast, staff were observed interacting well with service users. Service users were also observed rising at different times, staff stated that this varies particularly if service users have been awake during the night. One service users plan on the nursing floor contained information regarding sleeping patterns, which is deemed good practice. The inspectors spoke with the kitchen staff that stated that there is enough of each meal option sent to each floor to offer service users a choice. When the home is fully operational service users will be asked to indicate their individual choices prior to meals being prepared. At present the menus are on a fourweek cycle. On day one of the inspection concern was raised with staff at the time that the tea (including scrambled egg) was being prepared two hours before it was due to be served. Staff indicated that on this occasion they had started preparation a little earlier than necessary. On inspection the kitchens were clean and organised. Inspection of the food storage areas found that bread stocks were extremely close to the ‘best by’ date. On inspection of one of the satellite kitchens bread was out of date by three days. Staff maintain relevant daily checks on the temperatures of the fridge and freezers however records seen had gaps, one instance for a period of six days. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 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 standard(s) 16 All complaints or concerns must be appropriately investigated to provide the reassurance to service users that they will be listened to, taken seriously and acted taken. EVIDENCE: The registered manager investigates complaints and concerns that service users, relatives or staff may have. The registered manager is currently investigating one complaint and through discussion appears to be following relevant procedures and acting appropriately within timescales. However during the inspection it was noted in the communication book that a relative had complained to staff on the floor regarding the use of language. In this instance there was no evidence of an investigation being undertaken. Staff should support both relatives and service users to make complaints and record outcomes and action to be taken. As this is a new registration the financial systems are still being developed. Most of the service users have their finances managed by relatives. Records seen were accurate at the time of inspection. This standard will be inspected thoroughly at the next inspection. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 16 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 standard(s) 19,20,21,22,23,24,25&26 Service users are provided with comfortable surroundings each currently having their own rooms with en-suites. The home was found to be clean and free from odours. However if staff do not follow health and safety procedures service users and staff could be placed at risk. EVIDENCE: The location and lay out of the home is suitable to meet the service users needs. A tour of the premises was conducted. There were thirty-eight residents at the time of the inspection. The home is situated in a quiet residentail area of Hackney and 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. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 17 The staff provide snacks and drinks from small satellite kitchens, which are on each floor. The kitchen on the ground floor had an electric insect control device in place however there was no power supply evident. Some health and safety matters were brought to the attention of the managers: some fire doors would not close independently and some were wedged open, the swing door between the small and large dining areas poses a safety issue and it is suggested that the handle be removed from the large diner side, various plant room doors were unlocked. Additionally it was noted that the some of the signage on doors had been randomly applied for example the cleaners cupboards stated keep shut rather than locked, and laundry cupboards stated keep locked rather than shut. One cupboard, which was open on inspection, contained hazardous substanced. It is suggested that a complete audit is completed and signage correctly placed. 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. During the inspection the home was free from odour. 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. However on inspection of the driers it was noted that the lint required empting. The inspectors were informed that this is completed every other day however no records are maintained. The inspector was also informed that the staff had ceased using degradable bags for soiled items, this must be used to limit infections spreading. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 &30 The homes recruitment process was insufficiently robust as references were missing or required verification. This could mean that unsuitable staff have been recruited to provide care for service users. EVIDENCE: Rotas indicated that staffing levels were satisfactory and there were sufficient staff on duty to meet the needs of the service users. However on day one of the inspection the inspectors arrived on the top floor where service users were observed coming out of the dining area. The inspectors interacted with the service users and walked the floor, as no staff could be located. All three staff members were in a service users room having a discussion. The inspectors raised concerns about the lack of supervision for the remaining service users on the floor. Staff spoken to discussed the recruitment process and felt that they were employed within an equal opportunities framework. On examination of staff files there was evidence of staff having the necessary skills to meet the needs of the service users. Staff files contained CRB checks however it was noted that not all contained two references, in addition some that contained two did not have references verified by company stamps and or headed paper. The registered manager informed the inspector that twenty-two of the staff team would be commencing the NVQ course in the summer. Staff are also Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 19 undergoing assessment to determine if additional support is required for literacy and numeracy skills to be improved. Once staff are recruited they follow an induction programme and then shadow another staff member as supernumerary until assessed as competent. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,37&38 The home appears well managed however recordings being inconsistent reflect poorly on the service provision. EVIDENCE: The manager has completed the registration process and has many years experience in providing care. There is a clear management structure which staff were aware of. Through interviewing the registered manager, the inspector was satisfied that the home is managed in an open and positive way. Service users were seen to benefit from the ethos, leadership and management approach of the home. The staff and service users were friendly, open and appeared comfortable within the care home. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 21 Generally some of the recording was good in particular some of the daily recordings contained very descriptive details and staff had clearly given thought to the entries made. However this area needs further improvement. Gaps were noted in recordings of service users care, for example turn charts and nutritional intake records. Records where clear direction from outside professionals had been given were not always recorded. Gaps were also noted within medication records. 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. There had been incidents in the home that were reportable to the Commission however reports had not been sent. The monthly visits are now being undertaken on an unannounced basis. Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 22 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x 3 x 3 x x 2 2 Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 23 YES Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14.2 Requirement 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. The registered manager must ensure that all staff who upadte information on admssion have suitable skills and abilities. 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 The registered manager must ensure that all staff deliver care to service users appropriately to ensure assessed needs are met. The registered manager must ensure that all risks are assessed and risk assessments are updated. The registered manager must ensure that clinical equipment is appropriately used and set for individual service users as per Timescale for action 30/6/05 2. OP4 14.1(a) 30/6/05 3. OP7 15.2(b) 30/6/05 4. OP7 12.1 30/6/05 5. OP8 13.4 30/6/05 6. OP8 23.2 (c)12.1(a) 30/6/05 Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 24 the manufacturers instructions 7. OP8 13.1(a) The registered manager must ensure that service users have access where necessary to treatment, advice and other services from any health care professional. These needs must be documented on the service user plan. The registered manager must ensure that arrangements are made for the recording, handling, storage and safe administration of all medications in the home(Timescale of 31/3/05 not met) The registered manager must ensure that equipment for the safe disposal of medical equipment is supplied. The registered manager must ensure that fridge and freezer temprtures are recorded accurately. The registered manager must ensure that all used foods are within date. The registered manager must ensure that all staff are aware of service users cultural needs and that these needs are met The registered manager must ensure that all staff are aware of the action to take, according to their level of responsibility, if a complaint is made to them or a concern raised with them. The registered manager must complete an audit with regards to health and saftey issues as stated in this report and signage and ensure these issues are addressed. The registered manager must ensure that suitable equipment be used to reduce the risk of infection spreading. 30/6/05 8. OP9 13.2 30/6/05 9. OP9 13.2 30/6/05 10. OP15 16.2(g) 30/6/05 11. 12. OP15 OP15 16.2(i) 12.4(b) 30/6/05 30/6/05 13. OP16 22.1 30/6/05 14. OP19 23.4 30/6/05 15. OP26 13.4(c ) 30/6/05 Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 25 16. OP26 23.4 17. OP27 18.1(a) 18. OP29 19 19. OP37 17.1.2.3 20. OP38 37 The registered manager must ensure that dyers are cleaned regularly and records maintained. The registered managerl must ensure that there are sufficient staff on duty at all times to ensure that all the assessed needs of service users are met. The registered manager must ensure that there is evidence of a robust recruitment procedure, which includes obtaining all relevant documentation and mandatory checks. The registered manager must ensure that all of the homes records are accurately maintained. The registered manager must ensure that all notifications are forwarded to the Commission without delay. 30/6/05 30/6/05 30/6/05 30/6/05 30/6/05 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 Good Practice Recommendations Acorn Lodge Care Centre G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection 4th Floor, 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 G56 G06 S62717 Acorn Lodge Care Home V226380 050505 Stage 4.doc Version 1.20 Page 27 - 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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