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Inspection on 07/12/09 for Acorn Lodge Nursing Home

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

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

Each resident is registered with a local General Practitioner (GP) and where possible residents are able to retain their own GP. The home carries out an assessment of need on all prospective residents before an offer of a place is confirmed. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Family and friends are encouraged to visit regularly. Residents continue to like their meals and gave positive feedback when we asked them about meals and the quality of food served. The home offers residents pleasant surroundings with a variety of rooms in which they can sit during the day. The external parts of the home appeared to be well maintained and enjoyed by residents. Residents are able to bring furniture and other personal possessions to Acorn Lodge to make their rooms homely.

What has improved since the last inspection?

A formal pre admission procedure is in place. Such a procedure makes sure that service users receive correct information, receive a visit from someone from Acorn Lodge, have their personal and individual needs discussed and are given the opportunity to talk over any concerns they may have about a move into residential care. Skills for care induction programmes have commenced which should ensure that the basic standards are known to staff and they have the opportunity of receiving one to one support to maintain those standards and are monitored in practice.

What the care home could do better:

Though we know service users care plans have been developed they still require further development to include night time care plans and individualised plans which demonstrate how the service is supporting all the needs and requirements a resident may have including the management of unusual, difficult or unpredictable behaviours which can have an adverse affect on the service user. Acorn Lodge need to provide care plans that detail how staff will meet residents assessed needs. This will mean that all staff read the right information and help them to do their jobs even better. The care plans need to provide more detail and reflect the care residents’ need and who, how and when this is provided.Acorn Lodge Nursing HomeDS0000025427.V378059.R01.S.doc Version 5.2 Daily recordings residents’ achievements could be improved to contain more details and reflect their day-to-day life within the home. The manner in which medication is administered, recorded and managed continues to put people at risk. Despite being informed of their failings at the last key on 4th February 2009 and random inspections in August and November 2009, the registered provider and registered manager had not made sure service users received their medication safely which means they continue to be at increased risk of harm. During the course of the inspection we observed that some routines were based around staff rather than the preferred routines of residents. The registered manager should consult with residents individually to make sure that their current preferences are known regarding retiring at night, rising in the morning and for personal support such as bathing frequency etc. This should be recorded and monitored by the registered manager to make sure that staff as far as possible are carrying out support as the resident wishes. All staff need to be provided with training in adult protection so they are able to recognise signs of abuse and be aware of what to do if abuse is alleged. This will support residents’ safety. We are not kept informed of significant events at the home concerning residents; this means we do not always know what is going on within the home regarding residents’ health, safety and wellbeing. Records of all comments and complaints received at the home should be recorded as should the action taken to investigate and conclude where possible with a positive outcome for the complainant. This should give residents confidence that the registered manager takes seriously all complaints and comments raised. Management has a poor recruitment procedure with shortfalls in recording and processes not being evident. Staff are appointed and starting work without important documentation being received.

Key inspection report CARE HOMES FOR OLDER PEOPLE Acorn Lodge Nursing Home Guido Street Failsworth Oldham Lancashire M35 0AL Lead Inspector Kath Oldham Key Unannounced Inspection 7 and 8thDecember 2009 08:15 th DS0000025427.V378059.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Acorn Lodge Nursing Home DS0000025427.V378059.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 (35), Mental disorder, excluding registration, with number learning disability or dementia (25), Old age, of places not falling within any other category (60) Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To people of either gender whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP (maximum number of places: 60) Dementia - Code DE (maximum number of places: 35) Mental disorder, excluding learning disability or dementia - Code MD (maximum number of places: 25) The maximum number of people who can be accommodated is 85. Date of last inspection 4th February 2009 Brief Description of the Service: Acorn Lodge is a purpose built home situated on a main road close to the Failsworth/Manchester border, owned by Mr Goorwappa. The home provides accommodation for up to 85 people. The majority of bedrooms are single en-suite. One double room is provided for people who wish to share. Seven lounge/dining rooms, two quiet lounges and two conservatories offer a variety of settings in which people living at the home 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 off road parking for visitors’ cars. Fees for accommodation and care at the home range from £375 to £523 per week. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This visit was unannounced, which means that the owner, manager, staff and residents were not told that we would be visiting, and took place on 7th and 8th December 2009 commencing at 8:15am. We spent a little over twelve hours at the home. The registered manager and nurse advisor were available on the visit and provided us with information and records and support, in addition to the support from staff and residents. The inspection of Acorn Lodge included a look at all available information received by the Care Quality Commission (CQC) about the service since the last inspection which was held in February 2009. Every year the owner, person in charge or manager is asked to provide us with written information about the quality of the service they provide. Some weeks before our visit the owners or manager was asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. This helps us to determine if the management of the home see the service they provide the same way that we do. We considered the responses and information the registered manager provided and refer to this in the report. The AQAA received gave us only basic information about the service provided. The registered manager did not complete all the sections completely which meant we could not always tell what they had done to improve and how they were planning to sustain those improvements. There was no reference at all to the numerous requirements we issued on medication or how these had been addressed. The registered manager needs to refer to the guidance we provide in order to make sure the next AQAA contains enough information to evidence their efforts to improve and maintain standards. Acorn Lodge was inspected against key standards that cover the support provided, daily routines and lifestyle, choices, complaints, comfort, how staff are employed and trained, and how the service is managed. Comment cards were sent prior to the inspection for distribution to people staying and working at Acorn Lodge the views expressed in returned comment cards and those given directly to the inspector are included in this report. We also sent a comment card to some residents for them to pass on to their Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 6 relative, friends or advocates to obtain their views, opinions and feelings about the home. We received in total 20 comment cards from residents, relatives and staff. We got our information at the visit by observing care practices, talking with people staying at Acorn Lodge, talking with the registered manager, unit managers, some visitors and staff. A tour of Acorn Lodge was also undertaken and a sample of care, employment and health and safety records seen. The main focus of the inspection was to understand how Acorn Lodge was meeting the needs of residents and how well the staff were themselves supported to make sure that they had the skills, training and supervision needed to meet the needs of residents. The care service provided to four residents was looked at in detail to help form an opinion of the quality of the care provided. We call this case tracking. This is a way of inspecting that helps us to look at services from the point of view of the people who receive a service. We track residents care to see whether the service meets their individual needs. We looked at records and the care support of residents living at the home. We also spent time sitting with residents and observing their day to day routines as they received care support from care staff. This helped us get a better view about how people living at the home are looked after and supported. This also gave residents an opportunity to tell us about their opinions on the services provided at Acorn Lodge. We usually gather information through general contact with the home and through their reporting procedures, which are called Notifications, and information we may have received from other people, such as the general public and professional visitors. The registered manager has not kept us well informed since the last key inspection and has not provided us with the required notifications. Therefore we were not sure how the registered manager is dealing with significant events at Acorn Lodge. The term preferred by people consulted during the visit was residents. This term is, therefore, used throughout the report when referring to people living at Acorn Lodge A brief explanation of the inspection process was provided to the manager at the beginning of the visit and time was spent at the end of the visit with the Registered manager and Nurse Advisor to provide verbal feedback. References to we or us in this report represents the Care Quality Commission (CQC). On the last key inspection on 4th February 2009 the overall judgement of the service had gone from poor to adequate. We sent the registered person a warning letter on 26th February 2009 outlining persistent breaches of certain regulations. We asked them to send us an action plan by 16th March 2009 to Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 7 let us know what they were going to do to address these breaches or failings. This was received by us when we asked for it. On 17th August 2009 the pharmacist inspector undertook an unannounced inspection which means that the owner, manager, staff and residents were not told that we would be visiting, to make sure that the requirements regarding medication made on 4th February 2009 had been met. They hadn’t. We served a Statutory Requirement Notice on 10th September 2009 as they were in breach of the regulation relating to medication to make sure that they were aware of the areas of serious failings within their service which could lead to service users receiving their medication wrongly or not as prescribed and they were required by 7th October 2009 to comply with the medication requirements issued. A Statutory Requirement Notice is a legal notice, which is served on the provider when there has been a breach of regulations. The notice describes which regulations have been broken and what the provider must do to put right the breach; it also gives the date by which this must be done. We then follow up the notice by visiting the service to make sure that actions have been taken to meet the requirements and regulations. The requirements in this notice were made to make sure that residents health was not at risk from poor medication practices. The Statutory Requirement Notice made requirements that had to be complied with by 7th October 2009. In November 2009 the pharmacist inspector completed another unannounced inspection of the service to make sure they had complied with the requirements detailed within the Statutory Requirement Notice in relation to the safe handling, management and administration of medication. The outcome of that inspection was that the registered providers had not met all of the Statutory Requirements detailed within the Statutory Requirement Notice. The pharmacist inspector identified that the home had failed to meet fifty percent of the notice and it was the most important part of the notice they had not complied with. Because of this the registered providers are invited to attend an interview with us as part of our regulatory and enforcement procedures. This is scheduled to take place on 22nd December 2009. This report is a public document and should be on display within the home and can be made available for reading upon request. What the service does well: Each resident is registered with a local General Practitioner (GP) and where possible residents are able to retain their own GP. The home carries out an assessment of need on all prospective residents before an offer of a place is confirmed. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 8 Family and friends are encouraged to visit regularly. Residents continue to like their meals and gave positive feedback when we asked them about meals and the quality of food served. The home offers residents pleasant surroundings with a variety of rooms in which they can sit during the day. The external parts of the home appeared to be well maintained and enjoyed by residents. Residents are able to bring furniture and other personal possessions to Acorn Lodge to make their rooms homely. What has improved since the last inspection? What they could do better: Though we know service users care plans have been developed they still require further development to include night time care plans and individualised plans which demonstrate how the service is supporting all the needs and requirements a resident may have including the management of unusual, difficult or unpredictable behaviours which can have an adverse affect on the service user. Acorn Lodge need to provide care plans that detail how staff will meet residents assessed needs. This will mean that all staff read the right information and help them to do their jobs even better. The care plans need to provide more detail and reflect the care residents’ need and who, how and when this is provided. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.2 Page 9 Daily recordings residents’ achievements could be improved to contain more details and reflect their day-to-day life within the home. The manner in which medication is administered, recorded and managed continues to put people at risk. Despite being informed of their failings at the last key on 4th February 2009 and random inspections in August and November 2009, the registered provider and registered manager had not made sure service users received their medication safely which means they continue to be at increased risk of harm. During the course of the inspection we observed that some routines were based around staff rather than the preferred routines of residents. The registered manager should consult with residents individually to make sure that their current preferences are known regarding retiring at night, rising in the morning and for personal support such as bathing frequency etc. This should be recorded and monitored by the registered manager to make sure that staff as far as possible are carrying out support as the resident wishes. All staff need to be provided with training in adult protection so they are able to recognise signs of abuse and be aware of what to do if abuse is alleged. This will support residents’ safety. We are not kept informed of significant events at the home concerning residents; this means we do not always know what is going on within the home regarding residents’ health, safety and wellbeing. Records of all comments and complaints received at the home should be recorded as should the action taken to investigate and conclude where possible with a positive outcome for the complainant. This should give residents confidence that the registered manager takes seriously all complaints and comments raised. Management has a poor recruitment procedure with shortfalls in recording and processes not being evident. Staff are appointed and starting work without important documentation being received. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 10 order line – 0870 240 7535. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 11 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.V378059.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to make sure that residents’ needs are assessed before admission. EVIDENCE: As reported on past inspections the registered manager confirmed that admissions are only made to the home after an assessment of the residents needs has been undertaken. The registered manager also said that information from the care managers assessment of the placing authority or the funded nurse assessment is obtained in addition to their own assessment of needs. We reported on our last inspection that a resident had recently returned to the home following a hospital admission. The registered manager told us on that Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 13 inspection that it was not usual practice to reassess a residents needs following a stay in hospital. To ensure that the home can continue to meet the residents’ needs we recommended that prior to being discharged from hospital a further assessment of need is undertaken. The registered manager told us on this inspection that this now takes place. The recommendation has therefore been addressed. A recommendation was made in our August 2008 report that the assessment documentation should be further developed to show that people have been consulted about their lifestyle preferences, social interests, how they perceive their care needs and to show that they have been consulted on how they want to be supported. This recommendation had not been met when we inspected in February 2009 and due to the suspension on admissions being lifted the recommendation was reiterated in that report. We were told by the registered manager that a new section has been introduced on the care plan format to detail this. However the care files we looked at on this inspection did not include this detail. So we couldn’t see what residents’ preferences were. The next section of this report goes into further detail about this aspect of recording. A copy of the service user guide is available on each unit if anybody requests to see it. We were told that this has been updated since we last inspected Acorn Lodge. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care planning was insufficient to demonstrate residents’ health and personal care needs. Acorn Lodge do not manage medication well and residents health was at risk of harm from poor medication handling practices. EVIDENCE: We looked at four care files. The usefulness of the information that was written varied and did not always state the actions that staff needed to take or expected outcomes of any intervention or support. There were not always care plans in place for a variety of care needs identified in the care files we looked at. We couldn’t see a record in the care plan for things like residents preferences for when they like to get up or go to bed if they liked to have a bath or shower or when or how often they preferred to have one. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 15 The home should demonstrate that people are treated as individuals and that needs are assessed and prioritised individually. This would assist in demonstrating that the support provided is person centred. One resident commented that they get up at 6.00am, as they are reliant on staff getting them up so they get up to “keep the peace” when staff come. The resident did say they would like to get up a bit later. A further resident explained to us that they get up before 8.00am as night staff go off duty at 8.00am. There was nothing in residents care files that we looked at which indicated residents preferred rising and retiring routines. A resident told us that they liked to get up early but didn’t always get a drink when they got up. The resident told us it depends on which staff are on duty whether you get a drink or not on waking. In a care file we looked at for one resident it recorded from July 2009 to November 2009 the resident gaining about 5 kilogrammes in weight. It was only after four months that there was a record in November 2009 that the resident had been advised by the district nurse to cut down a little on potatoes and eat more vegetables. The residents care file also indicated entries by staff of specific amounts of insulin administered daily by the district nurse. The records didn’t match the actual records the district nurse had completed and can be misleading suggesting differing amounts of insulin had been administered. The district nurse records also detailed the residents’ daily blood sugar level, in addition to care staff records of the residents’ blood sugar level. On some days this would mean that the blood sugar level was taken four or five times if the records are correct and are an actual record of care staff taking these tests. There was no detail in the care file of how often the residents’ blood sugar levels should be checked and no indication as to what the correct levels should be and what to do if they weren’t. The care file didn’t detail what action should be taken in relation to this resident only that they were insulin controlled diabetic. It didn’t say anything about what this meant for the resident. There were no care plans in place for specific care needs such as how continence was promoted, as it had indicated been in the assessment form that for this resident there was a slight urine incontinence. A care plan for oral care was also not recorded. The residents’ personal hygiene needs were not recorded in a care plan in such detail to include whether the resident likes a bath or shower, how often they like to take one and at what time of day. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 16 The daily reports for this resident indicated that they were checked two hourly during the night but as there wasn’t a night time care plan it wasn’t clear what staff were checking. In another residents care file we looked at it only detailed very minimal information. It did say in this care file that the resident liked to have a bath as opposed to a shower. We made a recommendation on our last inspection to promote personal choice and people’s dignity that baths and showers depending on personal preferences are offered on a more regular basis. When we looked at the record which details when residents had baths we couldn’t see that this resident had received a bath on at least the previous four weeks. When we were looking at the bath records it identified that entries hadn’t been routinely made for other residents, which suggests they too were not having a bath. Staff told us for one resident we asked about that they had a bed bath as opposed to going for a bath or shower and this wasn’t included in this separate bath record. The records are used by staff to record when residents have baths or showers. The records do not demonstrate that residents bathe regularly. There was a record that this resident had lost over three kilogrammes in weight from the previous month. There wasn’t a new care plan in place to ask staff to monitor this or what action was being taken to keep the resident healthy. There was a blood sugar profile on this resident. It wasn’t clear why or when staff were checking these levels. There was no care plan in place to explain what should be done, why this should be done, how often and what action should be taken as a consequence of checking this. There was a really good care plan in place which gave clear guidance to staff as to what course of action should be taken when the resident had panic attacks. We made a requirement on our inspection in February 2009 to ensure that people are not placed at unnecessary risk, that a risk assessment for the use of bed rails must be further developed to include the risk of entrapment. We were told by the registered manager that the staff were using a new form from the local authority. When we looked at one care file we saw that it had an assessment for bed rails and a risk assessment. The risk assessment did not make any reference to the possible risk of entrapment as we had asked on the previous inspection. The nurse on duty told us that the resident didn’t have bed sides in place on there bed. When we went to look in this residents bedroom there were no bed rails. The registered manager told us that some new low beds had been purchased which meant that this resident no longer needed bed rails. The care file didn’t indicate this change. The resident was recorded as having had three falls in Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 17 April, August and October 2009. On the entry in October 2009 the resident was reported to have been “found on the floor at 10.45pm”. A second care file was looked at for a resident who had bed rails in place. This file did not detail any risk of entrapment. We don’t know whether these bed rails were still in place. There wasn’t a record that a review had taken place on this aspect of the residents care in November 2009 as there should have been. Where there was a record that monthly reviews had taken place. Some of the records we saw recorded the month and year and not the actual date the review took place as it should do. This detail would make it clear when the residents’ needs were reviewed. The details recorded in some of the daily reports were not acceptable comments to make about residents. This way of recording needs to be changed to promote the respect of residents. The manager needs to direct and support staff to complete the detail in the daily reports in a correct manner which is respectful and not judgmental or patronising to residents. The daily reports should be a record of how the care plan is put into practice and should detail each day and night the progress of a resident, the support and care they receive or any presenting problems or difficulties for a resident. The way the daily reports are being completed at the moment does not demonstrate the care and attention received by residents, so you can not be sure that the care they need is provided to them. To ensure that residents needs are assessed and action taken to maintain there health,safety,wellbeing and promote their abilities; staff do need to be clear what they are doing when they compile a care plan and need to demonstrate through accurate recordings the care and support provided to residents each day and night. Staff told us, “The home looks after the residents in a homely, caring, safe environment, and treats everyone as individuals”. “Looks after residents the best they can”. A resident told us that the home, “care well”. And the home needs to “keep improving on the quality of care”. Two residents said the home did, “everything” well and one added, there was “nothing” the home could do better. Further comments we received included, “The home cares for my X extremely well”. “Puts the patients first”. “It’s fine as it is”. A relative when asked what the home does well, commented, “takes good care of my X and added, “they care very much because of her dementia she is very bad now”. A resident told us, “I’d like to go to bed earlier approx 7pm”.and added, “I feel there could be more security regards male residents allowed to wander corridors and enter rooms unannounced and not invited. I hope this does not persist”. When we looked around the home on our arrival on the first day we noticed that a number of residents had there bedroom doors open wide Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 18 when they were still sleeping in bed. This practice doesn’t promote residents self respect and privacy. A relative indicated, “The service could improve the care of residents if more staff were employed (care staff). If residents are all demanding care staff cannot physically tend to individual needs”. And added, “my (cared for relative) is 90years old. I have been on a number of occasions to visit to find that X is very wet, X is incontinent and although I have been told X is on a two hourly change I don’t believe this is happening”. Records, reports and other correspondence, did confirm that, in the main, residents had access to routine and specialist health care, including general practitioners, dentist, district nurses, mental health nurses, dieticians, optician and specialist consultants through attending out-patients hospital appointments. Residents kept their own general practitioners whenever possible. A relative told us, “I get very frustrated when I visit my X and look in her wardrobe, I have spent a lot of money on clothes for her, and putting her name inside them, and only to find half the clothes in the wardrobe aren’t hers”. We made a recommendation on our last inspection, “to promote the dignity of people and prevent risk of cross infection people should have their own toiletries. A member of staff commented that the home could improve and “provide more cleaning, shampoo, bubble bath for residents”. When we looked around the building we saw some toiletries in the bathroom. Residents toiletries should be kept in their bedroom to ensure these are personal to them and are not used communally. The registered manger did say it was his expectation that toiletries are kept in residents bedrooms. We were told in the AQAA completed by the registered manager on 5th November 2009 that “we plan to continue training sessions by the pharmacist and assessment of competency of authorised staff who are responsible for the administration of medicines. Regular medication audits are undertaken by managers and pharmacist”. On 17th August 2009 the pharmacist inspector undertook an unannounced inspection which means that the owner, manager, staff and residents were not told that we would be visiting, to make sure that the requirements regarding medication made on 4th February 2009 had been met. They hadn’t. We served a Statutory Requirement Notice on 10th September 2009 as they were in breach of the regulation relating to medication and to make sure that they were aware of the areas of serious failings within their service which could lead to residents receiving their medication wrongly or not as prescribed. They Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 19 were required by 7th October 2009 to comply with the medication requirements issued. On 9th November 2009 the pharmacist inspector completed another unannounced inspection at Acorn Lodge to make sure they had complied with the requirements detailed within the Statutory Requirement Notice in relation to the safe handling management and administration of medication. The outcome of that inspection was that the registered providers had not met all of the Statutory Requirements detailed within the Statutory Requirement Notice. The pharmacist inspector identified that the home had failed to meet fifty percent of the notice and it was the pharmacist inspectors view that the most important part of the notice they had not complied with. Acorn Lodge do not manage medication well and residents’ health was at risk of harm from poor medication handling practices. Because of this the registered providers are invited to attend an interview with us as part of our regulatory and enforcement procedures.This is scheduled to take place on 22nd December 2009. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,&15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of activity means some residents are not provided with a stimulating environment and may become bored. EVIDENCE: There is a record of activities kept which details the activities that are available to residents. It was good to see that some residents were having activities organised to suit them or the circumstances. Each resident has a separate activity record and a lot we looked at said they didn’t take part. There were no entries in the daily reports on how the activities had impacted on the lives of the residents and whether it was something they liked doing. Some residents residing at Acorn Lodge have dementia or mental health problems and need interaction, stimulation and occupation led by staff, to enable them to have a good quality of life. We were told that the activities coordinator who works during the week spends an hour or so on each unit each day and there is a programme of organised activity like keep fit, reading Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 21 stories, arts and crafts and playing cards. This activities coordinator has just been appointed at Acorn Lodge and takes over from the previous coordinator. Some care staff were seen playing dominoes and other residents were being encouraged by staff to help with putting up the Christmas decorations and decorating the Christmas tree. For some residents they didn’t appear to have much, if any stimulation or occupation and sat for long periods resting, sleeping or just staring out at the room. Additional thought and time needs to be given to the stimulation some residents receive by providing imaginative ways of occupying residents and looking at them as individuals to see what can be provided to them. It is not suggested that everyone takes part in organised activity or more bingo is provided it is more about looking at the person and how they can interact and be stimulated in the day. A social assessment was in place in one residents care file we looked at and it gave some information about, past hobbies and interests, preferences then and now and abilities and skills. The detail hadn’t been updated to reflect getting to know the resident better over the months the resident had been staying at Acorn Lodge. Social assessments need to be developed for all residents and activities, stimulation or occupation tailored to suit their personal needs. Staff may benefit from receiving training to help them develop ways of creating an interesting and stimulating environment for people living at Acorn Lodge. Courses such as ‘Working creatively with older people’ and ‘Yesterday today and tomorrow’ which is a course about the effects of dementia could be something the registered manager could look at to enhance the stimulation of residents. The meal at lunchtime is indicated on a large flip chart in the (residential) lounge so residents are able to refer to this for reminders. Residents told us that sometimes there is a menu on display at other times they said they don’t know what they are having until it arrives. A resident and relative told us, “All the food is frozen that we are given”. We asked about this on the inspection and we were told by the cook that all the food is prepared at the home and the nurse advisor told us frozen vegetables are sometimes used. Another relative told us, “The meals at Acorn Lodge are very well balanced and are presented well”. A resident said, “Good balanced diet, ie plenty of vegetables/fruit”. We looked at the menus and there was a three week menu in place which showed at least two hot meal choices and three vegetables in addition to potatoes for the main meal of the day and a number of choices for the teatime meal. There was also a choice of sweet available to residents. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 22 Residents told us that they liked certain meals more than others and they let the cook know their views and opinions about the meals they have. One resident said, “You can have anything you want to eat at anytime”. One resident was heard to make compliments about the meal they were having and said “the chicken is beautiful”. We saw breakfast being served and had lunch with residents on the first day of our inspection. Residents were seen having a variety of hot and cold breakfast options. One resident told us they,” looked forward to breakfast”. Another resident told us, “they have a good variety at breakfast, I used to have a bacon butty but I was putting on too much weight so now have toast, it’s enough because lunch isn’t much after”. Breakfast is served from about 8.30am until such a time that all residents have eaten. Some residents we spoke to said they get up at around 6.00am and when asked said they didn’t have anything to eat until breakfast is served. Waiting until 8.30am for some residents is a long time and staff should be offering them something to eat earlier than this or breakfast should start earlier to accommodate residents’ preferences and rising routines. Staff should wear protective clothing when serving meals to promote best practice and minimise the risk of infection. When we arrived at the home on the first day of our inspection staff were seen serving breakfast without putting on their aprons which are available to them. Staff were directed by senior staff to put on aprons after the inspectors arrival. Residents told us that they sometimes get a drink when they get up in the morning, but this was dependent on which staff are on duty. Residents should be provided with a drink on rising as a matter of routine. Unless it is there expressed wish not to have one and this should not be dependent on which staff are on duty when residents get up. One resident told us they went to bed at 8.00pm and got up around 6.00am each day. At the lunchtime a resident told the Inspector what they were having for lunch. The meal when it came was different to what the resident had said they were having. They had in conversation with us said that they didn’t want vegetables and wanted chicken and roast potatoes and they didn’t care for gravy. When the meal arrived they were given mash potato, carrots and gravy with their chicken and when it was pointed out that the meal wasn’t what the resident wanted the meal wasn’t changed by staff. Residents should be supported in their meal choices and staff should act on what is being said in relation to residents’ individual preferences. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to a complaints procedure and have someone to talk to if they are dissatisfied with the service. EVIDENCE: We made a recommendation on the last inspection, that, to avoid confusion, there should only be one complaints procedure in place. We also recommended the complaints procedure be reviewed and amended to accurately reflect the procedure within Acorn Lodge. And that the registered manager should have a system in place to monitor all concerns and complaints to ensure that they are responded to in an appropriate and timely manner and any patterns of poor practice can be identified at an early stage and fully addressed. We were told by the registered manager that this recommendation had been addressed and there was one complaints procedure in place and all and any complaints are known to the registered manager and are responded to by him. A record should be maintained of all comments or complaints and the action taken to remedy the problem. This would demonstrate that the owner and manager take residents, their family and friends and staff comments seriously and they record the action they have taken to try to put any problems right. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 24 We were shown a complaints folder and we saw that one complaint had been received since we last inspected in February 2009 and a written response detailed the action taken to remedy the comments made. The complaints procedure should be used by the registered manager to demonstrate how the home has listened to comments and complaints and used to identify any problems or difficulties residents or their relatives are having which enables the home to develop the service they provide. A relative told us, “I get very frustrated when I visit my X and look in X’s wardrobe, I have spent a lot of money on clothes for X, and putting X’s name inside them, and only to find half the clothes in the wardrobe aren’t X’s”. These types of comments we would expect to see in the complaints record and the action taken to address the comments. Six staff who returned comment cards told us they knew what to do if someone has concerns about the home. Six residents said there was someone they can speak to informally if they are not happy and they knew how to make a formal complaint. Three relatives also told us that they knew how to make a formal complaint. Two relatives and one resident said they didn’t know how to make a formal complaint and one relative who completed the comment card on behalf of their cared for resident didn’t answer this question. We were provided with a list of training and the date that staff attended. The training list indicated that the majority of staff working at Acorn Lodge had taken part in what the home describes as “Abuse and Neglect” training. We were told that this is completed in house. The registered manager needs to arrange for the ten staff which were not indicated on the training list as having received this training to attend protection of vulnerable adults training. It would be good for staff to also experience external training. We discussed this with the registered manager to provide staff with an opportunity to receive training through the local authority with regards to the Protection of Vulnerable Adults. We looked in a sample of staff files; there were not always certificates to confirm staff attendance to training. We were told that training certificates are given directly to staff and that copies are not kept on staff files. This would be best practice and provide further evidence that staff have had the training indicated. We made a recommendation on our inspection in February 2009 that staff receive training on the Mental Capacity Act. The registered manager had received information about the Mental Capacity Act Deprivation of Liberty Safeguards and was awaiting information about when some more training about this was available so he could arrange for the remainder of the staff team to attend. We were told that twenty of the staff had attended this Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 25 training. The recommendation is ongoing until all staff have taken part in this training. We describe later in this report (Staffing Section) the omissions of the registered manager in obtaining criminal record bureau checks before staff start working at Acorn Lodge. Failure to follow the regulations in relation to recruitment of staff means that the registered manager does not know enough about someone in order to make a proper decision about whether they are suitable to work at Acorn Lodge. The practice of employing someone without the proper checks taking place first means that the registered manager does not fully safeguard residents from unsuitable people working at Acorn Lodge and reflects on the management of the home. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained and decorated to a reasonable standard. The standards of cleanliness and hygiene provide residents with a clean and pleasant place to live. EVIDENCE: In the AQAA completed by the registered manager before our inspection we were told,”the home caters for service users needs by providing a home from home environment so that they feel safe and secure. We also ensure that all staff are friendly and approachable and are receptive to each individuals needs. We have various policies in place including health and safety, fire and Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 27 infection control”. The registered manager also told us in the AQAA they also plan to, “Continue with our internal and external refurbishment”. A tour of the communal areas was undertaken and a number of bedrooms were looked at. The majority of bedrooms had been personalised. Some did look a little bland due to the colour scheme used in the home. Residents we spoke to said they didn’t have choices in what colour there bedrooms were decorated. All the bedrooms we looked at were warm and free from unpleasant smells. A resident told us they had been given a new larger bedroom and said they had everything they needed and the space available in the room was much better than there previous bedroom. A resident told us, “This home is clean at all times”. When we walked around the home on our arrival on the first day of the inspection some residents were in bed. There were a number of these residents bedroom doors wide open which doesn’t promote residents privacy, respect or dignity whilst in bed. The layout of the home promotes independence and people were observed mobilising and using aids such as handrails. There are aids to assist with bathing. The manager told us, “we have recently re decorated internally and externally, and new carpets have been fitted, and furniture and fittings have been replaced as required”. The division of the home into ‘units’ appears to encourage friendships and gives a homely atmosphere. One of the lounges on the ground floor had an unpleasant odour in the room which needs to be addressed by the registered manager. A resident told us, “Always clean and tidy and smells refreshing. The home is warm and comfortable”. A staff member when asked what the home could do better said, “Improvements to the general appearance of the home, which is ongoing”. A survey of residents confirmed their satisfaction with the home in terms of cleanliness and comfort. There was a requirement on the August 2008 inspection that the “external patio area must be risk assessed to ensure that a safe environment is provided for people wishing to use this facility”. This was because the patio area was uneven and was a potential tripping hazard to residents using it. On our inspection in February 2009 this requirement was repeated as it had not been addressed by the registered manager. The registered manager told us in the AQAA, “externally the rear garden has been greatly improved and the patio area extended, to provide more seating areas”. A risk assessment was also put in place prior to this work being undertaken. The requirement has now been complied with. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 28 A visitor’s book is placed in the hall and visitors to Acorn Lodge are encouraged to sign in and out. This is to ensure that in an emergency situation, everyone in the building is accounted for. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 29 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedures are not robust and compromise the safety of residents and staff. EVIDENCE: We asked staff if there are enough staff to meet the individual needs of all the people who use the service three staff said, “always” and four staff said, “usually”. Five staff told us that they felt they “always” had enough support, experience and knowledge to meet the different needs of people who live at the home and two responded, “usually”. We were told in the AQAA completed by the registered manager before the visit that eighteen care staff/registered nurses had left there employment at Acorn Lodge in the last 12 months. Acorn Lodge currently employ 40 full time and 13 part time care staff/registered nurses. Over the seven days prior to the day the form was filled in 240 hours had been worked by registered nurses and 1351.5 hours by care staff. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 30 The registered manager told us on this inspection that about 17 staff had started work at the home since we last visited in February 2009.We looked at five of these new staff files. We reported on the last inspection in February 2009 that there were some shortfalls in the recruitment process in relation to references and the lack of staff photographs or proof of identity. A requirement was issued that all staff files must include all the details listed in Schedule 2 to ensure the recruitment procedure protects residents. Recruitment and selection procedures should be in place to safeguard residents and offer a degree of protection to them. It is essential that the regulations be followed to promote this. For one new member of staff there was a gap in there employment record for a period of two years which was not recorded as having been discussed or explored at interview. For a second new staff member there was no indication of work or training details for a four year period. In another staff file we looked at there was not a record of employment or training or any explanation of what the staff member had done for a period of approximately 18 years. For another member of staff member there were no dates indicated on the job application form for previous employment so it could not be checked if there were gaps in there past employment. There should a full employment history for all staff together with a satisfactory written explanation of any gaps in employment. This ensures the registered manager has enough information about prospective staff to make a decision if they are suitable to work at the home. All the staff files we looked at indicated that staff had started work on receipt of a POVA first as opposed to waiting for the full criminal record bureau disclosure to be back. Staff should not start work until the POVA first check is back and should only work under supervision until a full criminal record bureau check is returned. Staff can start work in exceptional circumstances on receipt of the POVA first but only shadowing a member of staff. The registered manager could not evidence to us that staff were shadowing a member of staff who had all the checks taken out on them before there full criminal record bureau disclosure was returned. The manager must obtain a current Criminal Record Bureau certificate for all staff before they commence working at the home. This needs to be done before a new person starts work so that the registered manager can be sure they are suitable to work at the home. Failure to follow these regulations means that the registered manager does not know enough about someone in order to make a proper decision about whether they are suitable to work at Acorn Lodge. The practice of employing someone without the proper checks taking place first means that the Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 31 registered manager does not fully safeguard residents from unsuitable people working at Acorn Lodge and reflects on the management of the home. In one staff file we looked at there was information provided in the criminal record bureau check which should warrant some discussion with the member of staff. The registered manager had not undertaken this discussion satisfying themselves about staff they are employing to ensure they are the right people for the job. This omission has the potential to compromise the safety and wellbeing of residents. On the staff files we looked at there was additional proof of identity and health declaration forms in place but one health declaration form was not signed by the staff member and one was not completed but signed. We made a recommendation on the last inspection to have a set interview format and take notes during the interview process. In the newly appointed staff files we looked at a standard interview format was used and suggestions of what are good answers the interview panel should expect from prospective employees. In one of the staff files a tick had been put next to all the suggested good answers and no additional notes were made. In the others we looked at very few notes had been made. We would expect to see some notes on file if there have been gaps identified in the job application form or if staff haven’t filled out the job application form completely. Staff are required in the job application form to provide a statement that they have no criminal convictions. In one of the staff files we looked this section of the job application form had not been completed. We would expect that this would be discussed at interview and relevant notes made with confirmation of this signed by the prospective staff member. We also made a recommendation that written evidence be maintained that original documentation has been seen, the date and by whom. This was detailed in the staff files we looked at. All the staff files we looked at contained two written references which were recorded as having been received before staff started work at Acorn Lodge. Best practice would be to follow up by a telephone call to the referee prior to confirmation of employment. The training recorded provided to us on the inspection for nursing staff did not demonstrate that they had received training or updates to training in areas such as wound care, promoting continence or care of the dying. There was a record that three registered nurses had commenced palliative care training in August 2007.There was also a record that some registered nurses had Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 32 undertaken diabetes training in 2006 and dysphasia training which is about impairment in communication. Dysphasia is caused by damage to the part of the left side of the brain, which is responsible for language and communication. Registered nurses must be able to identify and address the many issues faced by stoma patients. Stoma care patients face a number of issues that can lead to embarrassment and distress. Patients rely on nurses to effectively resolve these issues that will relieve discomfort and embarrassment, and contribute to improved confidence. It is equally important that nurses are equipped with the relevant knowledge, enabling them to identify the cause of problems and deal with them effectively and appropriately. One nurse was recorded as having undertaken stoma care training in 2008. The national minimum standards indicate that there should be a minimum ratio of fifty per cent trained members of care staff (NVQ2 or equivalent) excluding the manager. The AQAA identified that thirty three staff have obtained NVQ training at level 2 or above. The percentage of staff with this qualification exceeds the national minimum standards and enables staff to have the knowledge and expertise to provide support to residents. Training needs were identified through the staff supervision programme. All staff who were spoken to or completed a comment card said they had opportunities to access ongoing training and development opportunities. One staff member, when we asked what does the home do well commented, “Provide staff training”. The registered manager told us in the AQAA that 10 staff had completed the induction training expected by the national minimum standards, described and recommended by Skills for Care. We asked to see the induction booklets for staff. We couldn’t ascertain where staff were up to in there induction training and there were no systems in place for the registered manager or unit managers to check how staff were or if they were progressing with this training or if and when they would be near completion. The nurse advisor told us on the inspection that they would set up a system to monitor staffs performance when undertaking their skills for care induction to support them in completing this vital part of there role. Not all staff have undertaken induction training to Skills for Care Specification which would assist staff in their understanding of residents and how to support them. The omission of this training compromises the care and support provided to residents. Induction training is vital to the success of staff recruitment and retention. The management should only confirm employment when they are satisfied that competence and progress has been shown to be satisfactory against these standards. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 33 Management has a poor recruitment procedure with shortfalls in recording and processes not being evident. Residents are not currently involved in the recruitment of staff. Staff are appointed and starting work without important documentation being received. Staff training had not been undertaken as is required. The records we were provided with on the inspection to detail training identified that some staff were not recorded as having undertaken updates to their moving and handling, fire safety training, health and safety, food hygiene, infection control, or first aid. This compromises the safety of residents and staff. Staff must be provided with training or updates to their training to ensure they have the skills and knowledge to support residents and do there jobs well. This must to be arranged to safeguard residents and staff. We have written in a previous section of this report (complaints and protection) that when we looked in a sample of staff files; there were not always certificates to confirm staff attendance to training. We were told that certificates are given directly to staff and that copies are not kept on staff files. It would be best practice to keep copies of certificates on file which would also provide further evidence that staff have had the training indicated. There are two nurses on duty during the day and one at night. The registered manager told us that this was due to there not being as many nursing residents as they are registered to accommodate. On the inspection there were 33 nursing residents. There was six care staff recorded on the duty roster on the nursing units during the day and two care assistants at night. The units are all staffed separately. On the downstairs units where there are residential residents there is a senior care assistant plus 5 or 6 care staff during the day and 4 night care assistants at night. The manager of the residential unit works during the day. When we looked at the duty roster we saw that staff are sometimes working 12 hour shifts. Staff confirmed this on our visit. It is registered managers responsibility to make sure that staff are able to do there job well at all times during there shift. A relative told us, “I think they need more than two nurses”. Another relative said, “The service could improve the care of residents if more staff were employed (care staff). If residents are all demanding care staff cannot physically tend to individual needs”. Staff also commented on this and said, “Pay more money, employ more staff”. “More staff on the floor would be nice”. A resident and their relative told us, “Staff could be more jolly and smile they are not happy at all it’s not a happy home at all”. A further relative said, “I personally cannot fault the home. All the senior staff and carers are excellent. I Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 34 can only praise the home and staff”. Other comments we received included, “the care staff on the whole are approachable”. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 35 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home which they like. There are areas of the service which continue to place residents at risk through incorrect management systems. EVIDENCE: The registered manager has obtained in July 2009 a Master of Arts degree in Health Care Law. In addition we were shown some certificates in relation to palliative care training in August 2007 and Diabetes awareness training in 2006. In the last twelve months the registered manager has attended pandemic influenza training. The registered manager should be considering Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 36 further training options to enhance and keep up to date his skills, knowledge and continued development. The registered manager has not demonstrated that he has systems in place for the monitoring of staff recruitment and the service provided, it appears that he relies on the findings of inspections. This means that service users do not receive a consistent care support service which ensures their health, wellbeing and safety at all times. Staff meetings are arranged which provide staff with an opportunity to influence how Acorn Lodge is run and contribute to its effectiveness. A member of staff told us, “The home also listens to the staff, who are made to feel they can talk to the manager at any time”. We reported last time that the registered manager had obtained an accident recording book in line with the Data Protection Act. And that once this book had been implemented, it was recommended that the registered manger analysis the frequency and number of accidents to assess patterns, possible cause and action to be taken to minimise occurrences. The accident book detailed accidents, incidents and occurrences experienced by residents. The current recording used at the home complies with Data Protection legislation. The manager audits the accidents and incidents that are reported at Acorn Lodge. An analysis is in place and needs further development to identify actions taken as a consequence to the analysis and any additional risk assessments or intervention put in place if required. Examination of the fire records identified that they had been recorded as having been completed at the regularity prescribed by the fire authority. These need to be undertaken regularly to ensure that equipment works. So if it is needed in an emergency Acorn Lodge can be assured that the fire equipment, emergency lighting and means of escape are operational. We reported on the inspection in February 2009 that there were no systems in the home for reviewing the quality of the service provided. We also reported that the registered manager should develop monitoring systems, within the home to review and improve the quality of care provided to residents living at Acorn Lodge. A quality assurance system should be in place that seeks and acts upon the opinions of residents in terms of their day to day experiences and improvements that could be made. The registered manager should then compile a summary report of the findings of the questionnaire survey to residents and include the findings to accompany the homes statement of purpose to evidence this consultation process. The Care Quality Commission (CQC) should also be provided with a copy of that report. Discussion with people, staff and the manager indicated that residents don’t have a formal opportunity to comment and influence what happens in the home. The requesting of comments about the service should include contacting Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 37 professional visitors to the home which may include health professionals, social workers or care managers. This would provide the opportunity for people to comment on the service on a formal basis. We asked to look at the most recent survey that the home had undertaken in the last 12 months. The registered manager told us that he couldn’t locate this information for previous years and they hadn’t requested comments in a survey from relatives or visitors this year. On the second day of the inspection the registered manager gave to us some comment cards completed by visitors who had come to Acorn Lodge the previous day. Resident meetings are arranged and we were told by the registered manager that posters are displayed around the home advertising this fact. A resident and their relative told us, “There are meetings but we are never told about them so are not asked to go to them”. There is a supervision process in place. Where staff meet with their manager to discuss their career development and their work and any training they feel is needed. We looked at the records of these meetings and were told by staff that they meet with their manager approximately every two months. We were told that Acorn Lodge did not manage residents’ personal finances. Residents or their representatives managed them. There were small amounts of money held on behalf of some residents for the purchase of toiletries and such like. The previous two inspection reports from August 2008 and February 2009 required that the owner must arrange regular visits to be made to Acorn Lodge, in accordance with regulation 26 of the Care Homes Regulations and provide the Commission with monthly reports until further notice. This requirement has now been met and the owners’ brother is undertaking these visits and the reports are being sent to us as we required. This requirement has been complied with. Maintenance records confirmed that electrical and gas safety checks were conducted in accordance with the relevant regulations. We usually gather information through general contact with the home and through their reporting procedures, which are called notifications, and information we may have received from other people, such as the general public and professional visitors. The registered manager has not kept us well informed since the last key inspection and has not provided us with the required notifications. Therefore we were not sure how the registered manager is dealing with significant events at Acorn Lodge. We also noted that we had not been kept informed about a number of accidents where medical attention has been sought for the resident. This means we were not always aware of what was occurring within the service. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 38 We were informed by the registered manager in the AQQA that in the last twelve months there have been 14 deaths at the home and 8 at hospital or hospice. We have not received any notifications about this as we should do in line with the regulations. We were provided with a notification on the inspection of a theft of two televisions from residents bedrooms that had taken place on the day prior to our inspection. The notification detailed the action taken once the theft had been identified. The registered manager told us the residents would receive replacement television sets through the homes insurance policies. We recommended on our last inspection that the policies and procedures were reviewed and updated to ensure they are personal to the home and contain up to date information in line with current good practice guidelines and current legislation. The AQAA completed by the registered manager detailed that all the policies and procedures had been reviewed in October 2009. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 39 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 40 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement To ensure that the health and welfare of people living at the home are fully met, residents receive the care and support they need at a time and frequency that is needed a detailed plan of care, which includes peoples personal choice and preferences, must be implemented for each identified care need. Previous timescale 09/03/09 had not been met. To ensure that people are not placed at unnecessary risk the risk assessment for the use of bed rails must be further developed to include the risk of entrapment. To ensure people are not put at risk an accurate record of fluids must be maintained, with particular reference to thickened fluids. Previous time scale of 09/03/09 and 25/09/09 had not been fully met. This requirement was not Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 41 Timescale for action 08/01/10 2 OP7 13 08/01/10 3 OP8 17 07/01/10 assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 4 OP9 13 There must be effective auditing systems in place system in place to check medicines are given correctly. Also systems to ensure staff that handle medicines are competent to do so safely to help make sure that people who live in the home are kept safe. Previous timescale of 26/10/08, 09/03/09 and 25/09/09 had not been met. This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 5 OP9 13 (2) Medicines must be given to residents as prescribed because receiving medicines at the wrong dose, wrong time or not at all can seriously affect their health and wellbeing. Previous timescale of 14/08/08, 12/10/08, 09/02/09 and 25/09/09 had not been met. This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 42 07/01/10 07/01/10 purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 6 OP9 17 (1) Clear and accurate records of medicines received into, administered and disposed of by the home must be maintained so that medicines can be fully accounted for to show that they are being given correctly and to prevent mishandling. Previous timescale of 14/08/08, 12/10/08, 09/02/09 and 25/09/09 had not been met. This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 7 OP9 13 All medicines must be stored safely and securely. Medicines must be stored at the correct temperatures so they work properly. Previous timescale of 09/02/09 and 25/09/09 had not been met. This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 43 07/01/10 07/01/10 8 OP9 13 Medicines that are prescribed to be given ‘when required’ must have clear written instructions for staff to follow to ensure they are given correctly. Adequate information about how to administer medicines must be available to ensure that they are given and handled correctly. Risk assessments must be done to assess the safety of residents if medicines are stored in their rooms. Previous timescale of 25/09/09 had not been met. This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 07/01/10 9 OP9 13 Put in place effective arrangements to ensure that medication is administered in accordance with the prescribers’ instructions and that administration is properly recorded. Compliance timescale of 8/10/09 was not met This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. 07/01/10 Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 44 The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 10 OP9 13 Put into place an effective system to ensure a record of stocks of medication stored in the home is accurately maintained and this includes accurate recording of medication received into the home and medications requiring disposal. Compliance timescale of 8/10/09 was not met This requirement was not assessed on the key inspection and the timescale of 09/11/2009 still stands. The date has been changed purely as the system doesn’t allow this document to be saved with dates previous to this inspection) 11 OP29 19 and schedule 2 All staff files must include all the details listed in Schedule 2 to ensure the recruitment procedure protects residents. Previous time scale of 09/03/09 had not been met. To provide safeguards to residents and staff and to comply with regulations. Ensure all staff have a criminal record bureau disclosure before they start work at Acorn Lodge. Provide all grades of nursing and care staff with training and updates to training which supports them to do there job well and maintains the health, safety and wellbeing of DS0000025427.V378059.R01.S.doc 07/01/10 08/01/10 12 OP30 18 31/01/10 Acorn Lodge Nursing Home Version 5.3 Page 45 13 OP38 37 residents. The registered person must notify the Commission of all events in the home that affect the health safety and wellbeing of residents as defined in regulation 37 07/12/09 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 Provide staff with training, direction and support on how to complete the daily reports in sufficient detail to accurately reflect the care given, in a way that is respectful to the individual resident. Include in residents individual plans of care details of their personal choice, preferences and social care needs. 2 OP10 To promote personal choice and residents’ dignity baths or showers, depending on personal preferences, are offered, provided and recorded on a more regular basis. To promote the dignity of residents and prevent the risk of cross infection residents should have their own toiletries which are kept in their bedrooms. To promote residents privacy, respect or dignity whilst in bed, review the arrangements for having residents bedrooms doors open. Additional thought and time needs to be given to the stimulation some residents receive by providing imaginative ways of occupying residents and looking at them as individuals, how they can interact and be stimulated in the day to see what can be provided for them. Provide residents with hot and cold drinks at all times DS0000025427.V378059.R01.S.doc Version 5.3 Page 46 3 OP12 4 OP15 Acorn Lodge Nursing Home which are offered regularly which should include providing residents routinely with a drink on rising. To ensure care staff have the knowledge and skills when serving food, they need to understand the procedures for food safety and attend food hygiene training or updates to make sure they know what they are doing and keep residents healthy and safe. Staff must promote best practice and have regards for the regulations in relation to infection control and ensure they wear protective clothing when serving meals. The registered manager should have a system in place which records all comments, concerns and complaints to ensure that any patterns of poor practice can be identified at an early stage and fully addressed. To ensure that people are not put at unnecessary risk safeguarding adults’ refresher training be provided to members of staff team who have not received this training. Consideration needs to be given by the registered manager for staff to attend external Protection Of Vulnerable Adults training through the local authority to support and continue staffs development. Eliminate the odours in the downstairs lounge. Provide residents with a choice of colour scheme when redecorating their bedrooms. Record all grades of staffs attendance to training to support for the future planning of updates and refreshers and to demonstrate staff have received training appropriate to do there job well. All staff who have not yet received training should receive training on the Mental Capacity Act. The registered manager should be considering further training options to enhance and keep up to date his skills, knowledge and continued development. A quality assurance system should be in place that seeks and acts upon the opinions of residents in terms of their day to day experiences and improvements that could be made. The registered manager should then compile a summary report of the findings of the questionnaire survey to residents and include the findings to accompany the homes statement of purpose to evidence this consultation process. The Care Quality Commission (CQC) should also be provided with a copy of that report. The registered manager must further develop the analysis DS0000025427.V378059.R01.S.doc Version 5.3 Page 47 5 OP16 6 OP18 7 8 OP19 OP30 9 10 11 OP30 OP31 OP33 12 OP38 Acorn Lodge Nursing Home of accidents to include the action taken to minimise occurrences and keep residents safe. Acorn Lodge Nursing Home DS0000025427.V378059.R01.S.doc Version 5.3 Page 48 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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