Inspection on 14/02/08 for Acorn Manor

This inspection was carried out on 14th February 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Acorn Manor 04/12/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Acorn Manor Woodville Heywood Road Bideford North Devon EX39 3PG Lead Inspector Adele Adams Unannounced Inspection 14 February 2008 12:20 th Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 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 Manor DS0000065498.V349239.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 Adults 18-65. 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 Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Manor Address Woodville Heywood Road Bideford North Devon EX39 3PG 01237 420777 01237 423623 arknursing@hotmail.com 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) Ark Care Services Ltd Mr Jesse Gillett Care Service 9 Category(ies) of Learning disability (9) registration, with number of places Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The five rooms without ensuite facilities must not be used to accommodate a service user until: 1. Ensuite facilities are fully fitted. 2.Certified by Building Control department. 3.Approved by the Fire Authority. 4.National Minimum Standards are met. Room 9, the ninth bedroom located on the lower ground floor of the annexe, currently used as a lounge, will only be used as a service user bedroom when an ensuite facility has been installed. The service is to be registered to accommodate 9 service users who have a learning disability and are within the age range of 18-65 years. 4th December 2006 2. 3. Date of last inspection Brief Description of the Service: Acorn Manor is registered to accommodate 9 people who have a learning disability and are within the age range of 18 - 65 years. The service is a large Georgian detached house situated on the outskirts of the small North Devon town of Bideford. The house is set in grounds of approximately 3 ½ acres and is approached by it’s own private driveway. The service has it’s own transport for and local transport services can also be used. Acorn Manor DS0000065498.V349239.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 2 star. This means the people who use this service experience good quality outcomes. This inspection was a planned key unannounced inspection, which began at 12:20 and ended at 18:30 on a weekday in February. The main purpose of this inspection was to assess the key standards together with any progress made with the requirements and recommendations that were made at the last inspection. When we arrived, people that use the service were at service, some were having lunch and some were resting or preparing for whatever they were planning to do that afternoon. We looked at most areas of the service and saw people’s rooms including their bathrooms and toilets, we also saw the sitting rooms, kitchen and dining areas and the laundry. During the day most of the people using the service were observed and spoken with if it was appropriate. Two of these people were case tracked; this means that we looked in detail at their records of care and medication. We also spent time speaking with care staff, the manager and the owner of the service. In addition, we read staff records, the service’s health and safety records, and some policies and procedures. Before this inspection took place, surveys were sent out to people including; people that use the service, their relatives, health care professionals and staff working at Acorn Manor. This was to try to give a wide range of people that use, have contact with and work for the service the opportunity to express their views about the service provided at Acorn Manor. People’s relatives completed and returned five surveys. Two surveys were completed and returned by people that use the service, two health care professionals completed and returned surveys and seven staff completed and returned surveys to us. All of the comments received helped us with planning this inspection. Information was also received from this service before the inspection, as asked for by the Commission for Social Care Inspection. This was in the form of an Annual Quality Assurance Assessment (referred to in the inspection report as an AQAA). The completed assessment provided us with important information that supported this inspection and has been included in this inspection report. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 6 In addition to this as part of planning this inspection, the last two inspection reports and their findings together with all other information provided and held about this service have also been taken into account. All of this information has helped to make judgements about how well the service meets key standards. The fees for this service vary for each individual and can be obtained from the service on request. What the service does well: This inspection found that there is a good approach to making sure that only people that have been assessed as appropriate move into Acorn Manor do so, this benefits both the new and current people using the service and helps to makes the move as smooth as possible. People that are able to are actively involved in their care planning and have free access to their records. The service is good at enabling people to make decisions and choices about their day-to-day lives. People have good access the community and take part in activities such as bike riding, swimming, bowling, cafes, tennis, football and visiting the cinema and theatre. The people also enjoy holidays, short breaks and outings. The service works hard to make sure that the people stay healthy by having good access to health care services outside the service. The level of staffing at the service is good and enables staff to meet people’ needs well. Each person has a key worker, this system works well helping people to establish positive relationships with staff. Acorn House has a Registered Manager who is supported well by staff who work hard to provide good care for people in a supportive and pleasant environment. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? This inspection has identified that improvements can be made in the following areas: The service’s pre admission assessment has improved – a new centralised assessment record has been introduced and is now in use. This makes sure that the same amount and quality of information is gathered for every prospective resident, and shows that all people are assessed in the same way. All people using the service now have a good care record in place that provides clear information about how their individual care needs are to be met. This helps to make sure and show that people at Acorn Manor do have their needs met in a safe, individualised planned way, with appropriate support and guidance from the staff. There are now well-written risk assessments in place for people using the service and this information is incorporated within the individual care plans to make sure the information cannot be overlooked. The medication policy has been be improved to include reference to resident’s being able to self medicate if this is assessed as appropriate which promotes independence. Homely remedies such as cold remedies are sometimes used by the service for people; these are listed in the medication guidance and this has been improved and shows that this is in agreement with the doctor and pharmacist. This information provides staff with up to date information which has been agreed with other health professionals, staff that access this information can then be confident with the action they take and that they have delivered care safely. Health and safety improvements have been made improving the safety of the environment for both people using the service and staff. Improvements include; ensuring that all windows that pose a danger to people now have a window opening restrictor in place, and the removal of gas taps from a person’s room preventing a trip or fall. Differences in floor levels are now clearly marked and notices are displayed informing people to take care. The service now allows for people’s rooms to have a lockable door, which can be accessed in an emergency via an override device. Quality Assurance and quality monitoring has been improved which will help to show the service’s commitment to putting the people first. The policies and procedures at Acorn Manor have been be reviewed and developed; this will help to make sure that the service continues to run well. The recording of routine safety checks has been improved and this now shows Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 8 that these checks are carried out regularly. 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. The summary of this inspection report can be made available in other formats on request. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The service’s performance was assessed against key standard 2. People who may wish to use the service provided at Acorn Manor have undergone an assessment process to determine whether their needs can be met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated; ‘We are very good at meeting the assessed needs of the people, due to our staff team having relevant training and experience. We provide our service users with a service user guide and statement of purpose. We ensure that only people suitable for the service are admitted. We ensure that where possible prospective service users visit the service prior to admission We are very good at liasing with other stakeholders and relevant proffesionals in order to ensure positive outcomes for service users.’ Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 11 We considered the information provided to us in the AQAA. We spoke with staff and they described the assessment process at Acorn Manor to us; we also read two people’s records that showed us what information is gathered about a person, which helps the service to assess if they can meet their needs. We also saw that the service has a new and improved assessment record called ‘ a centralised assessment record’ in place, this holds the useful information gathered during the assessment process and makes sure that each person using the service has a similar assessment of their needs undertaken. We also found from reading records and discussions with staff that the service works hard to try to enable people to visit Acorn Manor as often as needed before they move there and work closely with other professionals and families to make the move to Acorn Manor as smooth as possible for the person concerned. We did not discuss this matter with people that used the service during this inspection. The surveys we received from people using the service showed that people using the service were happy with the information they received about Acorn Manor before they moved there. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The service’s performance was assessed against Key Standards 6, 7 and 9. People living at Acorn Manor are involved in decisions about their lives, and take part, as they are able to in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘We provide our service users with the opportunity to be involved in a wide variety of activities ranging from self support skills such as cooking, household tasks etc. through to community based activities such as dancing, shopping, swimming, horse riding etc. These are identified by the service user with support where neccesary, and full risk assessments carried out. This allows the service users to make informed choices about what they wish to do and to take appropriate risks. Each service user has an individual care plan which Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 13 clearly identifies the service users needs and aspirations. Where possible the service user plays an active role in planning their care, where this is not possible trhen other stakeholders are consulted. Where needs are identified which we cannot meet internally we liase with appropriate external proffesionals, such as speech and language therapist, Psychiatrists, CLDT, G.P etc. All service users are encouraged to speak to their care managers on a regular basis and if they are not able to then staff will do so for them. Staff are made aware of confidentiality on their induction including its limits i.e disclosure of abuse.’ We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us by people that use the service, we read two individual care records in detail, we spoke with the Registered Manager, we spoke with two staff, we observed people that use the service and staff and spoke with a person that uses the service. We saw detailed care records that contain appropriate and useful information and which are regularly reviewed with people that use the service. We saw that there are good risk assessments in place – we read these and saw that these are referred to in the individual care plans. We pointed out to the Registered Manager that Risk Assessments although much improved, should be signed and dated and that it is good practice to plan a review date. We were advised that the service aims to review these at least once every three months. We observed staff working with people that use the service and saw how people are enabled to make decisions; this was also evident in care plans that we read. The surveys that had been completed by people that use the service, informed us that people do make decisions about their lives and do have choice in what they do throughout the whole day. The person that uses the service that spoke with us, told us about how they had spent their day and what they were planning to do later in the evening and later in the week. They told us how the service provides them with the support they need to live a life that they are happy with. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The service’s performance was assessed against key standards 12,13,15,16 and 17. People at Acorn Manor receive a well-balanced diet and are supported to participate in activities within the home, make use of local facilities outside the home and go on regular trips and outings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘Several of our service users attend social activities with peers both from inside and outside of the service. One of our service users plays for a LD football team. One Service user has requested anger management counselling, which we have helped them to access. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 15 All servcice users have an activity plan, which they formulate with staff help. Service users have the opportunity to continue activities they did prior to coming to the service as well as trying new ones. Service users are involved where possible in planning their own holiday arrangements. In house activities are run weekly by an art teacher and a music teacher. One of our people uses a gym at least once a week, and another is about to start doing so, as well as all those who choose to access the local swimming pools. Our people cycle on a local cycle trail, and where required we hire special bikes in order to facilitate this. Our people are supported in eating out in local cafés, restaurants and pubs and shopping in the local community. All food is freshly prepared and is balanced.’ We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us by people that use the service and their families, we read two individual care records in detail, we spoke with the Registered Manager, we spoke with two staff, we observed people that use the service and staff and spoke with a person that uses the service. We found that people really do get involved and are supported to make choices about their lives. We found that people had been supported to go to college, go dancing, horse riding, and on the day of inspection one person enjoyed a trip to a swimming pool. We saw that people are able to go on holiday and on the evening of the inspection, a person was being supported to go out for an evening meal – which is something they enjoy doing on a regular basis. Another person told us about how they are trying to improve their health and fitness and we observed a conversation between them and a member of staff that confirmed this. Care records read by us contained details of activities enjoyed by people and risk assessments related to activities that had been undertaken to minimise and identify risks to the people involved and what actions were necessary to ensure peoples safety. During the inspection we observed activity in the kitchen just after mealtimes, we also saw what safety measures/ risk assessments were in place in relation to kitchen activities. References to people’s dietary needs were seen in their care records and people have their weight monitored as part of ensuring a healthy lifestyle. Food is freshly prepared each mealtime and individual needs and special dietary needs can be catered for. Staff told us they had done a food hygiene course. We saw that fridges and freezer temperatures are recorded appropriately. We saw that there is an adequate supply of dry and fresh food at the home. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 16 Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The services performance was assessed against key standards 18, 19 and 20. People living at Acorn Manor have their care needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘We have excellent links with health and social care services within the local community. All service users are registered with a G.P., Dentist, Optician and Consultant Psychiatrist as well as having access to the local CLDT. The staff support the service users in accessing these services whenever needed. Service users are involved in identifying the level of personal support they require and how that is delivered. Sometimes due to their level of understanding it may be neccesary for staff to take the lead in this. The way in which the support is then delivered is clearly recorded in the service users care plan. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 18 All medication is dispensed by appropriately trained staff and is also witnessed. Each people medication is kept in an individual locker in order to reduce the risk of error. All people have a self medication risk assessment and where appropriate a self medicating program.’ We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us, we read two individual care records in detail, we spoke with the Registered Manager, we spoke with two staff, we observed people that use the service and staff and spoke with a person that uses the service. The two care records that we read clearly showed the person’s personal care needs, physical and emotional needs and medication needs – evidence of healthcare needs being met were also seen during case tracking and included: details of the doctor they are registered with, and the involvement of other healthcare professionals including; a consultant psychiatrist, and a dentist. We observed staff and saw that staff communicate respectfully with people about their physical, emotional and medication needs and that people generally responded well to the staff. We saw that a new appropriate medicines storage facility is in place and is working successfully. We saw that medication guidance and policies had been reviewed and now include information about people that may be able to self medicate if this is assessed as appropriate – and the homely remedy section of the medication policy had been addressed following the last inspection and is now satisfactory. We observed one person being supported in a really positive way by staff with taking their medicines – they are not able to independently self medicate safely but are supported by staff to take their medicines as independently as possible in a structured, safe way and in such a manner that increases their self esteem and confidence, this is an example of very good practice. The Medication administration records were read by us – unfortunately some gaps were found – for example records had not been signed in some cases, so it was difficult to be certain whether or not medicines had been given. We were told that only staff that had received medication training are able to give people their prescribed medicines. The staff files read by us showed that staff do receive medication training. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The services performance was assessed against key standards 22 and 23. There is a clear complaint procedure in place at Acorn Manor and people are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘To my knowledge there have been no complaints or protection issues within the service. However there are clear Pova and complaints policies in place, and a copy of the complaints procedure is in the service user guide. All instances of service user aggression are clearly documented, including steps taken to resolve the incident. Staff are trained in intervention and prevention techniques (NAPPI). Detailed records are kept of all Service users financial transactions. All service users have there money kept locked away securely. There is a policy in place precluding staff from receiving gifts from people or their families, or benefitting from or witnessing client wills.’ We considered the information provided to us in the AQAA. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 20 In addition to this, we read the surveys that were returned to us, we spoke with the Registered Manager, we spoke with two staff, read two staff records, we observed people that use the service and staff and we read the complaints policy. The Registered Manager and the service provider informed us that no formal complaints have been received by the service. The two members of staff that spoke with us were aware of the complaints procedure and demonstrated that they understand what to do if a complaint is made or if they should wish to make a complaint. The staff also confirmed that they had received training relating to safeguarding vulnerable people and that they knew how to respond appropriately to any inappropriate behaviour, actions, suspicions or allegations. The staff records that we read also showed that staff had attended training in this area. Our observations of staff and people using the service and reading of care records and surveys shows that people do openly express their views and concerns with the service and are supported by staff to do so. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The services performance was assessed against key standards 24 and 30. Acorn Manor provides people with a clean, and comfortable home to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘The service is set within large grounds and is within short walking distance of the town. All bedrooms have on suite facilities and are lockable by the occupant. There is a large amount of internal communal living space. All bedrooms are furnished to meet the needs of the individual. Service users can bring any furniture they wish to with them. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 22 Appropriate window restrictors are fitted to allow ventilation. All staff have lockers. There is an outside smoking area for service users and staff.’ We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us, we spoke with the Registered Manager, we spoke with two staff, read two staff records, we observed people that use the service and staff and we walked around and observed the accommodation provided for people by the service. On the ground floor there is a large central hallway with two generously sized rooms, one used as a sitting room, one used as a smaller sitting room and an activities room and a third smaller room, that is used as an office. The main kitchen is spacious. Kitchen equipment is safely stored. There is a table and chairs for resident and staff use. There is also a second kitchen that provides additional dining / activity area. The laundry has been re- sited, there are 2 washing machines and 2 dryers; we discussed the need for the walls and floors to be washable with the Registered Manager and service provider. The service uses appropriate clinical waste systems and has the ‘yellow and red bag’ systems in place. Each person has his or her own-labelled laundry baskets. A curved staircase in the main hallway provides access to the upper floor. The hallway is large and is now furnished – feeling more homely and welcoming. We saw some people’s rooms; these all have appropriate furniture and are also personalised with the people’s own possessions. People have their own private bathroom facilities. One person has the use of a dedicated kitchen and bathroom – risk assessments are now in place for this kitchen. We saw that window restrictors have been fitted to upstairs windows. We found that following the last inspection gas taps in a room had been removed to prevent a trip or fall. Differences in floor levels that are clearly marked and notices are displayed informing people to be careful – people’s rooms now have lockable doors which can be accessed in an emergency via an override device. We were informed by the manager and service provider that there are plans in place to cover all radiators and that there are risk assessments in place that show levels of risk have been accounted for – these were seen in records read by us. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 23 Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The services performance was assessed against key standards 32, 34 and 35. People using the service benefit from a staff team that are trained, competent and well supported to do their job. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘All staff are given a copy of the GSCC and also do the SKills for care induction pack. all staff have a contract spelling out their role and responsibilities. Staff receive regular supervision. All staff have the opportunity to do NVQ level 2 or 3 Staff support the service users to access appropriate services. All staff have appropriate checks prior to commencing work, including CRB and references. The service is also supported by agency staff – the agency is owned by the Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 25 same provider and the same recruitment arrangements are in place The AQAA also provided information about numbers of staff, the hours they work and what qualifications they have, at the time of writing the AQAA the service employed 9 permanent staff with NVQ Level 2 or above and that 5 are working towards NVQ Level 2. We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us by people that use the service and their families, we read two individual care records in detail, we spoke with the Registered Manager and the service provider / owner, we spoke with two staff, read staff rotas, staff records, and we observed people that use the service and staff. The staff records that we read showed that the service has good recruitment practices in place and that correct recruitment information is held on file and that appropriate staff checks are carried out. The staff that we spoke with confirmed the way the recruitment of staff takes place and this confirmed what we had read in staff records. Staff spoke to us about the training they can access and the records that we read show that staff do access regular training, on the day of inspection training in learning disability and mental health was being attended. A member of staff had attended training in Autistic Spectrum disorder in January and further staff training had been organised for staff in March covering Learning Disability and sexuality. Staff confirmed that they had undergone an induction period – however two staff records did not hold induction information – this was discussed with the Registered Manager. We observed that there are enough staff available to care for each person’s individual needs, staff also told us that this was the case. We were told that there has been more staff stability recently and both people using gthe service and staff have felt this to be of benefit. Staff told us that they do have one to one supervision meetings, we saw evidence of this in staff records – the frequency of these meeting was discussed with the Registered Manager as this needs to be increased. . Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The services performance was assessed against key standards 37 and 39 and 42. People that use the service provided at Acorn Manor benefit from a well-run service, where their views are taken into consideration and health and safety issues are taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated, ‘The registered manager has the qualifications and experience as required and oversees the implementation of policies and procedures. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 27 The manager is always available when on duty to both the service users and the staff, and the service is also supported by an on call manager, should a situation arise requiring a management decision when the manager is not on the premises. Open discussion and ideas are encouraged. Staff are judged solely on their work performance. Comprehensive records are kept, and an access to records policy is in place. A senior member of staff ( manager or team leader ) is present for on site 7 days a week & there is also an on call management rota.’ We considered the information provided to us in the AQAA. In addition to this, we read the surveys that were returned to us by people that use the service and their families, we read two individual care records in detail, we spoke with the Registered Manager and the service provider / owner, we spoke with two staff, we read various policies and procedures, staff meeting minutes, health and safety records and quality survey forms, we also observed people that use the service and staff. The team at Acorn Manor is led a registered manager, staff told us that they found him professional and approachable and had confidence in his abilities and that he had made positive changes. Staff told us that the home is run very well and that the people that use the service come first. The Service provider told us that she was very pleased with the positive achievements that the Registered Manager has made since joining the service and the commitment that he shows. People using the service and staff were observed to be comfortable with the Registered Manager. Regular staff meetings are held and we read some of the minutes taken at these meetings. The registered manager discussed Quality assurance processes with us and showed us that quality assurance questionnaires had been returned and that the results and outcomes were in the process of being collated – we read some of these questionnaires. We saw that the policies and procedures at Acorn Manor have been updated, reviewed and where necessary renewed. Reading of the homes health and safety records which show that regular checks such as; fire checks, drills and quarterly evacuations take place, that regular health and safety checks such as; the recording of fridge and freezer temperatures takes place. Staff receive moving and handling training and first aid training, first aid boxes are kept on site. Kitchens have first aid boxes, fire blankets and fire extinguishers in place – fire extinguishers are checked by an external company once a year in addition to the visual checks carried out by staff - this annual check was carried out 29/01/2008. A fire policy and risk assessment is in place – the registered Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 28 Manager advised that he has requested an external assessor come into the home to do a fire risk assessment. Visual Health and Safety checks show that regulations are adhered to, such as; potentially dangerous substances such as cleaning materials are appropriately stored, dangerous implements are safely stored and staff have the equipment they need to safely care for residents – such as personal alarms. Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 SERVICE Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE SERVICE Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO 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 Services Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA9 Good Practice Recommendations Risk assessments should be improved to show when they have been written, who has written them and when review is recommended. Medication records should be signed to show clearly whether or not a person has taken their prescribed medicine. All staff should have had the opportunity to have a period of induction - this is to make sure that all staff have received the same information and have the same knowledge and understanding about the service. All staff should have regular one to one supervision. 2. 3. YA20 YA35 4. YA36 Acorn Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Manor DS0000065498.V349239.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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