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Inspection on 10/10/06 for Acorn Lodge Nursing Home

Also see our care home review for Acorn Lodge Nursing Home for more information

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The internal and external appearance of the home provides a pleasant, comfortable environment for residents to live in and residents and visitors said the home was always very clean and tidy. Residents were complimentary about the staff saying that they were friendly and helpful. One resident felt that the home was a "good" home with a pleasant and relaxed atmosphere and visitors said they were always made welcome. Staff worked well as a team and were seen to be patient and kind to residents. The quality of the meals was praised by residents who all said they enjoyed the food provided and felt there was a good choice. 50% of care staff are trained to at least NVQ level 2.

What has improved since the last inspection?

Since the last inspection an activities organiser has been employed who had started to ask residents about what type of leisure and social activities they would be interested in doing. This work has stopped at the moment as the activities organiser is on leave of absence but the owner hoped to carry on with this work as soon as possible.Staff were more aware of the necessity of considering what social and mental stimulation could be provided for residents and were seen spending time with residents, chatting and reading the newspaper etc.

What the care home could do better:

Although all residents are assessed before they come into the home, shortfalls in the planning of care lead to a risk that residents will not receive the proper care they need. Residents` health care needs were not always monitored accurately and staff had not always been proactive in seeking further advice regarding medical conditions. Employment recruiting and vetting practices were unsafe in that criminal disclosures or Povafirsts had not been consistently obtained before the new employee started work in the home. Other records such as references were not always available. This means that people living in the home are potentially not protected from someone with a criminal or abusive background. Although resident/relative questionnaires had been sent out to get feedback about their opinions of the home, few residents meetings seemed to have taken place. The owner and manager should consider what further means they can use to ensure that people living at the home are able to make suggestions about how the home is run. Although staff had received training in a range of topics, there were shortfalls in the induction training of new employees and staff did not receive supervision sessions that would enable them to discuss the aims and objectives of the home and their training needs etc.

CARE HOMES FOR OLDER PEOPLE Acorn Lodge Nursing Home Guido Street Failsworth Oldham Lancashire M35 0AL Lead Inspector Mrs Fiona Bryan Unannounced Inspection 10th October 2006 09:15a 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 Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 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 Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Lodge Nursing Home Address Guido Street Failsworth Oldham Lancashire M35 0AL 0161 681 8000 0161 688 8088 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Aneerood Goorwappa Mr Goinden Kuppan Care Home 85 Category(ies) of Dementia (25), Dementia - over 65 years of age registration, with number (25), Mental disorder, excluding learning of places disability or dementia (30), Old age, not falling within any other category (40), Physical disability (20), Physical disability over 65 years of age (20) Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No more than 45 places to be used for nursing care. No service user aged under 55 years to be admitted to the home. 1 RMN to be on duty throughout the 24 hour period. One Registered Nurse to be on duty throughout each 24 hour period plus one additional Registered Nurse for 12 hours per week. Service users to include 25 DE, up to 25 DE(E), up to 40 OP, up to 30 MD, up to 20 PD and up to 20 PD(E). 26th July 2006 Date of last inspection Brief Description of the Service: Acorn Lodge is a purpose built home situated on a main road close to the Failsworth/ Manchester border. The home provides personal care for up to 40 service users accommodated on the ground floor. In addition the home provides general nursing care for up to 20 service users and specialist care for up to 25 service users with dementia. Fees for accommodation and care at the home range from £313.88 to £508.69 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Service users requiring nursing care are all accommodated on the first floor. The home is owned and operated by Mr Goorwappa and a manager who is also a registered nurse assists him in the management on a day-to-day basis. The majority of bedrooms are single en-suite. One double room is provided for couples or service users who wish to share. Seven lounge/dining rooms, two quiet lounges and two conservatories offer a variety of settings in which service users are able to receive visitors, socialise and participate in activities. The home is on a main bus route with a bus stop outside. There is ample parking for visitors cars. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection which included an unannounced visit to the home took place on 10th October 2006 and was conducted by two inspectors. Time was spent talking with residents visitors and staff. Staff interaction with residents the overall ambience of the home was noted and the effect that it had on the residents. Five residents were looked at in detail, looking at their experience of the home from their admission to the present day. A tour of the building was conducted and a selection of staff and residents’ records was examined including records of care, medication records, employment and training records and staff duty rotas. What the service does well: What has improved since the last inspection? Since the last inspection an activities organiser has been employed who had started to ask residents about what type of leisure and social activities they would be interested in doing. This work has stopped at the moment as the activities organiser is on leave of absence but the owner hoped to carry on with this work as soon as possible. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 6 Staff were more aware of the necessity of considering what social and mental stimulation could be provided for residents and were seen spending time with residents, chatting and reading the newspaper etc. 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 Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 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 Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 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): 3 The quality in this outcome area is adequate. Information collected during assessments is not always fully used to develop detailed care plans; therefore residents cannot be certain that the home can meet their needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Five residents were case tracked. Four residents had assessments from social services, which were kept separately from the main care file. One resident had been admitted as an emergency admission and the home had completed an assessment on his admission. The majority of assessments were quite detailed. However, as discussed in more detail later in this report, care needs that were identified in the assessments were not always documented in the care plan. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 9 Although staff were knowledgeable about the majority of residents’ care needs and daily routines, one staff member was not aware of some important aspects of one resident’s care who had recently been admitted. Further consideration should be given as to how information about newly admitted residents is relayed to all staff. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 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 and 10 The quality in this outcome area is adequate. Care plans do not always provide staff with the information they need and risk assessments do not always accurately identify potential risks and are not reviewed properly. Systems for monitoring the healthcare needs of residents are not consistent. This means that residents’ personal, health care or social needs may not be met. Procedures for dealing with medicines in the home are generally satisfactory; some minor improvements are needed. Personal support within the home is offered in such a way as to promote residents’ privacy and dignity. This judgement has been made using available evidence including a visit to the service. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 11 EVIDENCE: Five residents were case tracked. As stated previously care plans had not always been developed to address all the needs that were identified in the residents’ assessments. For example one resident had osteoporosis but no care plan had been implemented to evaluate and monitor the effectiveness of treatment although it was clear from the daily record that the resident needed to take frequent painkillers. Another resident had no care plan to address their emotional needs although the daily record referred to their low mood several times. Care needs that developed after the resident had been admitted were not always recognised or recorded. For example one resident was clearly extremely uncomfortable due to a bad rash on their chest and neck, and also had very sore eyes, but care plans had not been commenced for either of these issues. The daily record for this resident provided no evidence of any care or treatment being offered to the resident in respect of these 2 health problems. Care plans, especially on the ground floor were vague and far too generalised. They contained very few details of the specific preferences and capabilities of individual residents. Care plans were slightly more person-centred on the general nursing unit but still contained a lot of “stock” phrases that were applied to many residents in a very generic way. Some of the residents’ more diverse needs need to be considered and planned for more carefully, for example one resident who was profoundly deaf, again had a very generalised plan to address his hearing difficulties but there was no evidence that all possible options had been explored to promote his independence and enhance his quality of life. Care plans and risk assessments were usually reviewed monthly but risk assessments were not always accurate. For example the nutritional risk assessment for one resident should have been much higher but staff had not entered a score to reflect the fact that the resident had recently lost weight and had not adjusted the score to indicate that the resident now needed help to eat rather than being able to eat independently as they had previously. District nurses who were visiting the home at the time of the inspection said staff followed their advice and stated that residents generally looked fairly well presented, clean and tidy when they visited. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 12 However, the inspector was concerned that on the ground floor, health care needs were not always being followed up in a suitable timescale. For example, although the GP had prescribed cream for a resident’s rash, there were no means in place for staff to formally monitor the effectiveness of the treatment and they had been applying it for several weeks with no apparent effect but had not taken steps to discuss this further with the doctor. Examination of medication administration records (MAR) indicated that in the main medicines were managed appropriately. On a small number of occasions medication administration details had been handwritten. These transcribed details had not been validated by an additional member of staff. Although the register for controlled medicines was maintained accurately staff had not signed the individual MAR to record when a CDA had been administered to the resident. The controlled drugs register provides an audit trail of CDA’s in the home but the MAR records the administration to the resident and must be completed as well. Residents said staff were caring and kind. “Staff look after us alright”. The home had sent out satisfaction surveys to relatives and one had commented, “I feel I am kept well informed of my … health and staff are always ready to answer any questions” and another said, “I am very happy with the standard of care”. Positive interactions between staff and residents were noted. One staff member was observed asking a resident very discreetly if they wanted to go to toilet. Several staff members were patient and relaxed with a resident who was very agitated. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 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 and 15 The quality in this outcome area is adequate. Although some efforts are made to provide social stimulation this area needs to be improved to meet all residents’ social, cultural and recreational needs. Visitors are encouraged and welcomed into the home and feel supported by staff. Residents have some choice over aspects of their daily lives. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the last inspection an activities organiser had been appointed who had started to discuss with residents what their individual interests and social preferences were. It had been planned that this information would then be transferred to the residents’ care plans and a programme of activities would be developed that would meet residents’ needs and capabilities. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 14 However, it was reported that the activities organiser had been on leave of absence for several weeks and it was unclear if they would be returning to work. In the meantime the provision of social activities remains limited. On the ground floor there were no care plans for residents’ social care needs and little reference was made in the daily records as to how residents had spent their day. Residents said they were bored and wanted more to do. Describing their daily routine a number of residents said they got up and had breakfast about 8.30am, then sat in the lounge until lunchtime. After lunch they sat in the lounge again. One resident said “we usually nod off” and another said, “I hang around here”. On the general nursing unit staff had been working with Age Concern in writing Life Stories for some residents. Staff had gathered information about the resident’s childhood, career, family, holidays and hobbies etc with anecdotes and photographs and Age Concern had used this to produce the resident’s Life Story. The unit manager said staff enjoyed reading them and it was planned to continue with this work for all residents. On the unit for people with dementia carers chatted with residents on a one to one basis; one carer was reading a newspaper with a resident and music was playing. The atmosphere was calm and relaxed. Visitors said they were always made welcome at the home and one relative said, “staff are like a family to us and we are more than pleased with the home”. Residents confirmed that they could get up and go to bed as they wished and could spend time in either one of the lounges or their own room as the preferred. Residents were complimentary about the food provided by the home, saying there was a choice and they enjoyed the meals. Lunch on the day of the inspection was minced beef hash, or fish cakes, boiled or roast pots, carrots, green beans and peas and gravy. Dessert was peaches and cream or yoghurts. Staff were aware of residents’ dietary needs and were flexible to meet the needs of residents, for example serving one resident with their lunch about half an hour earlier than everyone else as they were agitated and saying they were hungry. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 15 Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 16 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 and 18 The quality in this outcome area is adequate. The home has a satisfactory complaints system and residents feel that any complaints would be listened to and acted upon. Staff training in adult protection has ensured that staff are aware of the issues and provides a safe environment for residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home’s complaints procedure is usually displayed in the reception area of the home but had been taken down when the area had been redecorated; however the owner said he would ensure it was put back on display. It was reported that there had been no complaints since the last inspection. Although none of the residents spoken with could recall seeing the complaints procedure, all were clear as to what procedure they would follow, and what the home would do if they had cause to make a complaint. The majority of staff had received training in safeguarding adults, which had been provided by Oldham Social Services. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 17 During this inspection there was no evidence to suggest that residents were being actively discouraged from walking around the home, which had been the case at the last inspection. However, one resident on the ground floor was very sleepy and the unit manager said all they did “was sleep and eat”. This resident was prescribed frequent sedatives and the unit manager said it was “probable” that this was causing the resident to be very sleepy. Care should be taken that the use of sedatives is appropriate and not merely used as a form of chemical restraint in dealing with residents with challenging behaviour; there was no evidence in this resident’s care file that other interventions had been explored in managing any aggressive behaviour. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 18 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 and 26 The quality in this outcome area is good. The home provides a safe, clean environment with appropriate aids and adaptations to promote residents independence. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home maintains a good standard of hygiene and cleanliness for residents. Communal space includes six lounges one of which is no smoking and a conservatory area. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 19 Single bedroom accommodation is provided for residents with many rooms having en-suite facility. Residents’ rooms were homely and personalised with several residents choosing to stay within their rooms. One resident said, “ I prefer to stay in my room and listen to music”. Three bedrooms had been redecorated. The inspector noted that some others areas of the home were in need of redecoration and several chairs in the lounge areas needed to be refurbished or replaced. The management team had also recognised this and included these areas in the homes refurbishment plan. Bathrooms and toilets are provided with sensor lights to aid those residents with a disability. Aids and adaptations are provided in bathrooms and toilets. The outside garden areas are well maintained. To the rear of the home is a safe enclosed garden area provided with garden furniture for resident’s comfort. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 20 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 and 30 The quality outcome for this area is adequate. Staffing levels were in proportion to the needs of the residents. However the failure to implement staff inductions in line with skills for care training may pose a risk to residents. The home meets the standard for the percentage of care staff who have completed NVQ training. The lack of effective staff recruitment procedures may pose a risk to residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Examination of the duty rota and staff allocation showed there were sufficient staff to meet the needs of residents at the time of this inspection. Each member of staff had a training record in place. An analysis was undertaken, which stated 50 of staff had completed NVQ2/3. The home employs a trainer who is qualified to deliver training in moving and handling, health and safety and also best practice in care issues. Prevention of Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 21 Vulnerable Adults training is accessed through the local social service training section. Staff gave examples of additional training which included managing challenging behaviour, dementia awareness and infection control. Not all staff training and induction records were maintained to a good standard. The homes induction needs to be brought in line with Skills for Care induction process. Interviews with staff and examination of induction procedures found that inductions were not always undertaken or only in a brief format. Examination of recruitment and selection procedures found that these posed a risk to residents. In some instances there was a failure to obtain two references or criminal bureau checks prior to commencement of employment. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 22 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, 36 and 38 The quality in this outcome area is adequate. The manager is well supported by senior staff and is competent to manage the home. The home has a quality assurance system in place, which provides opportunities for residents, relatives and professionals to give feedback. The lack of effective communication systems and staff supervision may pose a risk to residents. Health and safety is maintained to ensure the safety of residents. This judgement has been made using available evidence including a visit to the service. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home’s manager has a number of years experience in care and is a qualified Registered Mental Health Nurse. They have continued their professional development through attending short courses in prevention of pressure sores, medication and diabetes awareness. The manger on the ground floor residential unit has undertaken refresher training in moving and handling and diabetes. Residents, relatives and professional questionnaires had been sent out for completion. Twenty five per cent had been returned and there were a number of positive comments. Questionnaires had also been sent to other professionals that visit the home and a social worker had responded stating that they “considered the home to be good in all disciplines.” The manager reported that residents’ meetings were held on the residential unit; however, minutes were not available for inspection. No residents’ meetings had taken place on the nursing units. Staff meetings do take place, however the last staff meeting was held in June 2006. The home received the Investors In People award in 2005. Records are maintained of any transaction entered into on the resident’s behalf. It is usual practice in the home for residents or their relatives to be invoiced for any expenditure. Staff supervision was not maintained. This was evident through examination of record keeping and staff interviews. In some instances staff were unaware of service users’ needs as documented on their care plan. Records required by regulation for the protection of residents were not accurate or properly maintained; this has been discussed previously in this report relating to staff recruitment and staff induction. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 24 Appropriate maintenance checks had been carried out on equipment in the home i.e. lift maintenance, fire risk assessment, nurse call and gas and eclectic safety. Staff had received training in fire procedures. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 25 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14, 15 Requirement Timescale for action 30/11/06 2 OP7 15 3 OP8 13 4 OP9 13 The registered person must ensure that care plans are reflective of pre-admission assessments and set out in detail the action that needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the resident are met. (Timescale of 28/2/06 not met). The registered person must 30/11/06 ensure that care plans are updated to reflect changing needs and current objectives for health and personal care. The registered person must 30/11/06 ensure that risk assessments are accurate and health care needs are monitored appropriately and advice sought from other health care professionals in a timely manner. The registered person must 30/11/06 ensure that where controlled medicines are administered to residents, their medication administration record is signed. Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 27 5 OP29 19 6 OP30 18 The registered person must ensure that all staff has two references and a criminal record bureau check prior to commencement of employment. The registered person must ensure that on commencement of employment all staff receive induction in line with skills for care. 30/11/06 30/11/06 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 Refer to Standard OP7 Good Practice Recommendations The registered person should ensure staff have access to care planning and allocated time for reading in order to raise awareness on the needs and health conditions of residents. The registered person should ensure that handwritten medication details on the medication administration records are validated by an additional member of staff. The registered person should ensure that all options are explored and documented when managing challenging behaviour and that where sedatives are used these are proportionate to the residents’ needs. The registered person should ensure that regular staff and residents meetings take place, which are minuted. The registered person should ensure that a programme of activities is arranged that provides facilities for recreation for all residents including those that are more dependent and those with dementia. The registered person must ensure that staff receive supervision a minimum of six times a year. 2 3 OP9 OP18 4 5 OP33 OP12 6 OP36 Acorn Lodge Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Nursing Home DS0000025427.V315213.R01.S.doc Version 5.2 Page 29 - 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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