Inspection on 04/12/06 for Acorn Manor

This inspection was carried out on 4th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Acorn Manor 14/02/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Acorn Manor Woodville Heywood Road Bideford North Devon EX39 3PG Lead Inspector Adele Adams Unannounced Inspection 4 December 2006 10:50 th Acorn Manor DS0000065498.V315304.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.V315304.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.V315304.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 Homes Ltd Mr Bruce Ashley Martin Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Acorn Manor DS0000065498.V315304.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 home is to be registered to accommodate 9 service users who have a learning disability and are within the age range of 18-65 years. N/A as newly registered 2. 3. Date of last inspection Brief Description of the Service: Acorn Manor is registered to accommodate 9 residents who have a learning disability and are within the age range of 18 - 65 years. The home 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 home has it’s own transport for residents and residents can also use local transport services. This is the service’s first inspection therefore this is the home’s first inspection report. The provider advised in the pre inspection questionnaire that the fees for residents living in the home range from £ 1,600 to £ 3,495. In addition to these fees, residents also pay for chiropody, hairdressing and toiletries. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (C.S.C.I) has introduced “Key Standards “ to be inspected. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. This inspection was an unannounced inspection and the focus was on the key and environmental standards. The inspection took place between 10:50 and 16:45, lasting six and a half hours. Acorn Manor is registered as a care home for nine residents with a learning disability. The home was registered in February 2006 and home has a motivated Registered Manager who is supported by a deputy manager and a team leader. During the inspection, the inspector spent time speaking with and observing 4 residents, time was also spent speaking to care staff and the manager of the home. A tour of the home was made, during which all rooms and accommodation were viewed and a selection of records that included the residents’ records, staff records, the home’s health and safety records, and policies and procedures were read. A completed questionnaire and a completed residents survey were provided to C.S.C.I before this inspection was carried out. These provided useful additional information that has been included in this report 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, this benefits both new and current residents and makes the move as trouble free as possible. The level of staffing at the home is good and enables staff to meet residents’ needs well. Each resident has a key worker, this system works well helping residents to establish positive relationships with staff. Residents 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 residents also enjoy holidays, short breaks and outings. The service works hard to make sure that the residents stay healthy by having good access to health care services outside the home. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 6 Mealtimes at Acorn Manor are flexible and tailored to suit the residents. Staff and residents eat together and enjoy the food. Attention to the residents diet and weight related health and care needs are good. Acorn House has a Registered Manager who is supported well by staff who are working hard to provide good care for residents and meet the National Minimum Standards. What has improved since the last inspection? What they could do better: This inspection has identified that improvements can be made in the following areas: The residents’ pre admission assessments could be improved by ensuring the same approach and information is gathered for every prospective resident, as this shows that all residents are assessed in the same way – the information gathered also provides important baseline information for the service to refer back to when reviewing resident’s care. All residents should have a care record which provides their care details, this will help to make sure that the residents have their needs met in a safe, individualised planned way, with appropriate support and guidance from the staff. The residents risk assessment should be mirrored in the planned care, as this will make sure that this important information is not overlooked. Risk assessments for activities such as kitchen activities should be in place to ensure that risks to residents are highlighted and taken into consideration when planning this type of activity. Residents should also have risk assessments in place showing that the environment they use is safe, for example to show why radiators in the home are not covered. Staff records should be available for inspection in the home in case these are needed out of normal working hours. The medication policy should 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 in the home for residents; these are listed in the medication guidance but do not show that this is in agreement with the doctor and pharmacist. This information should be Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 7 updated and will then provide 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. The recording of medication given to residents and the handwriting of prescriptions must be improved to reduce the risk of mistakes to residents. The service could improve upon the adult protection information staff receive by making sure that new staff receive adult protection training. Health and safety improvements to the home are necessary to improve the safety of the environment for both residents and staff. This includes, ensuring that all windows that pose a danger to residents have a window opening restrictor in place, that the gas taps that are not needed in a resident’s room are removed to prevent a trip or fall. That differences in floor levels that must be clearly marked and have notices displayed informing people to take care. The home does not currently allow for residents rooms to have a lockable door which can be accessed in an emergency via an override device this could be improved upon. The recording of routine safety checks can be improved this will then clearly show that these checks are regularly carried out. The approach to staff training could be improved to ensure that all staff regularly receive training and up to date information about, food hygiene, infection control and medication. This will give staff confidence that they are delivering care both in the safest way and in the safest environment. Quality Assurance and quality monitoring can be improved which will help to clearly demonstrate the service’s commitment to putting the residents first. The policies and procedures at Acorn Manor are to be developed and improved upon; this will help to make sure that the service continues to run well with the residents best interests being supported and looked after. 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.V315304.R01.S.doc Version 5.2 Page 8 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.V315304.R01.S.doc Version 5.2 Page 9 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): Key Inspection 4/12/06. The homes performance was assessed against key standard 2. Quality in this outcome area is good. Residents receive sufficient information to help them decide whether Acorn Manor is the right place for them to live. Residents are assessed before admission and this ensures staff can meet their needs. EVIDENCE: It was not possible to discuss this standard in depth with each resident, one resident was spoken with and they explained how their move to Acorn Manor had taken place and that they had visited before moving there. Two residents’ records were read to see what information is gathered before a resident is admitted to the home. The same level of assessment should be carried out for each prospective resident. The residents do have pre admission assessments carried out, the quality of these varies depending upon where and who has provided the information. The pre admission process carried out by staff at Acorn Manor is not yet formally recorded in a structured manner. However, the Registered Manager developed a form during the inspection that is to be considered for future use in this area. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 10 The deputy manager and the team leader advised that potential new residents and their care manager are met by the provider and the registered manager, when an assessment is made, the deputy manager has also been involved in this process. If following an initial assessment it is felt that Acorn Manor may provide the right environment for the potential new resident, they are able to visit and spend time at the home before choosing to move in. A resident told the inspector that they had done this. Relatives were not in attendance at this unannounced inspection, therefore their views could not be obtained. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 11 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): Key Inspection 4/12/06. The homes performance was assessed against key inspection standards 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents at Acorn Manor have adequate individual plans explaining how their assessed needs will be met, the residents risk assessment are also adequate and could be improved however, staff do support the residents to lead independent lifestyles which includes taking risks. EVIDENCE: A resident was spoken with and gave an account of how they are supported by staff and a view of what it is like for them to live at Acorn Manor. The resident was aware that records are kept. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 12 One resident does not have a care plan in place – this is to be addressed by the deputy manager. The 2 residents care records read contained risk assessments - these were not very informative. The risk assessments in another resident’s records were over 6 months old and had been provided by the previous care manager on the resident’s admission to the home. The risk assessments had not been reviewed and contained out of date information about the resident. Risk assessment for kitchen activities and night times were missing from one resident’s records – this was discussed with the deputy manager and the team leader. A further member of staff confirmed they get involved in residents risk assessments and care records and made reference to the need for these to be reviewed at least once every six months. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 13 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): Key Inspection 4/12/06. The homes performance was assessed against key standards 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents 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. EVIDENCE: The inspector spoke with and observed residents and read records and case tracked x 2 residents records in respect of: Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 14 Meals and mealtimes – these are very flexible, special dietary provisions are made, there is access to snacks and drinks and the dining area/ kitchen The lunchtime meal was briefly observed; the staff and residents ate together and enjoyed the food. Two resident’s records were case tracked to find out what records are made and kept about their diets and whether or not they have any special dietary needs. The records showed that both the attention to and the recording of the residents diet and weight related health and care needs are good. The home keeps a record of the food served and this was provided and read. Fresh fruit and vegetables are available and other foodstuffs / products in the home are of good quality. Health and safety monitoring records were read – such as fridge temperatures – cleaning rotas (night staff only follow a rota). Additional domestic support is given twice a week. The inspector observed areas in the kitchen and found that the kitchen was clean and has appropriate storage facilities. A fire extinguisher, fire blanket and First Aid box are available in the kitchen. A resident and Staff were spoken with about the activities that are available both inside and outside the home. This showed that a variety of trips out and activities are undertaken and that these are usually on a one to one basis. Two residents’ records were case tracked and contained details of their individual wishes – for example their likes /dislikes, the contact residents have with their family and friends and the visits and outings that they go on. All residents’ rooms were seen during the inspection; the rooms are spacious and show each resident’s individuality, the residents spoken with liked their rooms. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 15 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): Key Inspection 4/12/06. The homes performance was assessed against key standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at Acorn Manor have their care needs met satisfactorily. EVIDENCE: Two residents’ care records were inspected, these showed the resident’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: a resident attending the doctor, and the involvement of other healthcare professionals including; a consultant psychiatrist, a chiropodist and a dentist. The inspector spoke with and observed staff and a resident about the residents’ personal care needs and how these are met, this showed that residents are satisfied with the way in which their care needs are met. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 16 The residents’ records were read and residents and staff were observed this enabled the inspector to see that staff communicate respectfully with the residents about their physical, emotional and medication needs and residents responded well to the staff. The lack of available information in one of the care records read was discussed with the deputy manager and team leader – the deputy manager is aware of the situation and is to address this. The inspector looked at the arrangements in place for giving residents medicines on an ‘as required’ basis and found everything to be recorded and stored appropriately. Medication guidance and policies are available in the home and were read by the inspector, these do not include reference to resident’ being able to self medicate if this is assessed as appropriate – the deputy manager advised that the policies are currently under review, there is a homely remedy section to the medication policy which was discussed with the deputy manager who was not fully aware of the legislation relating to this section of the policy and is to ensure this is addressed. The residents Medication administration records were read by the inspector – these highlighted that there was a gap in the medication record where the record had not been signed and handwritten prescriptions had not been signed by a doctor or witnessed and signed by a second member of staff – the deputy manager was made aware of this and is to rectify the situation. Medication storage facilities were inspected and were found to be satisfactory – the inspector discussed the storage facilities with deputy manager. A pharmacist has not undertaken an inspection at Acorn Manor. The deputy manager told the inspector they had undertaken a modular medication course; one staff file did not contain evidence that they had undertaken medication training. One member of staff confirmed they had not received training provided by the pharmacist specifically related to the monitored dosage system used by the home. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 17 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): Key Inspection 04/12/06. The homes performance was assessed against key standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear complaint procedure in place at Acorn Manor and residents are protected from abuse. EVIDENCE: One of the residents spent time speaking with the inspector, they explained what they would do and who they would go to if they were unhappy about something, the resident felt able to approach any of the staff but would probably go to their key worker or the registered manager. No complaints have been received by the home since it opened in February 2006. Two members of staff were spoken with and advised they had not received adult protection training since they joined the home. They had received this training in their previous jobs but one said they felt the training they previously received was not very good and that further information / training would be valuable. Staff were aware that there is a complaints procedure and process and described what action they would take if a complaint were made. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 18 The policy and procedure for concerns and complaints and the protection of vulnerable adults was read, there are plans for these to be renewed/ updated. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 19 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): Key Inspection 04/12/06. The homes performance was assessed against key standards 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Acorn Manor provides the residents with a clean, and comfortable home to live in. However, in some areas of the home the safety of the residents is at risk EVIDENCE: On the ground floor there is a large central hallway with two generously sized rooms and a third smaller room, it is planned that this will be used as a quiet room. The main kitchen is spacious and is located on the ground floor. Kitchen equipment is safely stored. There is a table and chairs for resident and staff Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 20 use. There is also a second kitchen that is not currently in use by, it is proposed this will provide an additional dining / activity area. The laundry is spacious and domestic in character, the floors and walls are washable and a hand washing needs to be installed as agreed in the registration process and the current sink is used to clean off soiled linens. A member of staff advised they had not undertaken any infection control training or education in the past few years another member of staff had undertaken infection control training in 2004. There was a boiler room to the right of the entrance hall, which now provides a newly installed disabled toilet facility and a smaller boiler room. A curved staircase in the main hallway provides access to the upper floor. The hallway is large and not furnished – it is not particularly welcoming. The rooms located off a half landing on the staircase are not for resident use as access is hazardous. The inspector saw all of the residents’ rooms, these are all single rooms and have appropriate furniture and are also personalized with the residents own possessions. The inspector was shown residents armchairs that are waiting to be repaired. Residents have their own private bathroom facilities. One resident has the use of a dedicated kitchen and bathroom – risk assessment is not in place for use of this kitchen the deputy manager advised this will be addressed. An inspection was undertaken in November by the local food and safety team which identified that the service needs to ensure, as discussed at the homes registration site visit, that window restrictors must be fitted to all upstairs windows. Risk assessment in relation to falls from upstairs windows were not in the 2 resident care records that were read. The inspection also identified that gas taps in a residents room could cause a trip or fall – this is still to be acted upon and was raised with the deputy manager who advised that this will be addressed. It was also found that there are several small differences in floor levels that must be clearly marked and have notices displayed informing people to be careful – Residents rooms do not have a lockable door which can be accessed in an emergency via an override device, which was identified as necessary during the home’s site visit – the inspector was advised that this is due to there being safety issues for residents – this has not been risk assessed. Radiators are not covered and risk assessments have not been undertaken to demonstrate whether or not radiator covers are needed – this was discussed Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 21 with the deputy manager and identified as an area for action. Fire extinguishers and fire blankets are in place, as is a fire alarm and smoke detection system. The fire installation and commissioning certificates were dated 20/01/06. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 22 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): Key Inspection 4/12/06. The homes performance was assessed against key standards 32, 34 and 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents at Acorn Manor are cared for by appropriate numbers of recruited staff, however the approach to ensuring all staff have appropriate training in areas such as food hygiene, infection control and adult protection needs to be more sound. EVIDENCE: Staff records were made available for inspection – discussion took place with staff and the provider about the importance of all records including staff records being available at all times for inspection. The two staff records read showed that the necessary checks had been taken before people are employed to work at Acorn Manor. The two staff spoken with about their applications to work at the home and confirmed Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 23 that the correct recruitment process and checks are followed and undertaken before they were employed to work at Acorn Manor. The staffing rota at the home was read and this showed that appropriate levels of staff are on duty at the home, staff and a resident also confirmed this. A staffing rota was also provided before the inspection with the pre inspection questionnaire this also showed appropriate levels of staff on duty. The inspector was advised that all residents receive individualised care from a member of staff between the hours of 8am and 8pm. On the day of inspection, there were 5 members of staff on duty plus the registered manager. At night there is one member of staff on duty with the back up of an additional member of staff sleeping in. The inspector read the home’s policy in relation to residents receiving care from staff of the same gender. The inspector noted that at the time of the inspection, the night staff were both male and discussed the appropriateness of this with the registered manager and was advised that female residents do not currently need any care at night and that it is planned that there will always be a female member of staff on duty from one week’s time. The information provided on the pre inspection questionnaire which was completed by the Registered Manager states that all staff at the home have an NVQ Level 2 qualification or above. The Registered Manager has gained the Registered Managers Award and the deputy manager has an NVQ Level 3 qualification and is undertaking the Registered Managers Award. A member of staff was spoken with about the training provision for staff working at Acorn Manor. They confirmed they had received an induction when they began at the home at have also received training in the following areas: food hygiene, emergency first aid and manual handling training. They had received Adult Protection and medication training at the home they had previously worked at but had not had an update since joining Acorn Manor. The information provided on the pre inspection questionnaire completed by the Registered Manager states that staff training in the last year has included, risk assessment, fire training, T.O.P.P.S induction training, safe handling of medicines, first aid, food hygiene and moving and handling training. Another staff member advised they had not received food hygiene training for ‘some years’ the training certificate held on file indicated that this has been due for renewal. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 24 A member of staff felt the Adult protection training they received before working at Acorn Manor could be improved upon and would like to increase their knowledge in this area. The registered manager advised that staff do have individual training records. These were not looked at on this occasion. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 25 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): Key Inspection 4/12/06. The homes performance was assessed against key standards 37 and 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Acorn Manor is run by staff that put residents first, and communicate well with the Commission for Social Care Inspection. The Quality Assurance processes and areas of health and safety at Acorn Manor need to be improved. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 26 EVIDENCE: The inspector spoke with staff, spoke with the manager of the home, read the pre inspection questionnaire, read two residents records, toured the home, spoke with and observed residents and read the health and safety monitoring and servicing records. Acorn Manor has a registered manager, deputy manager, a team leader and a small team of staff, some staff are supplied by the provider’s care agency – the inspector was advised that it is planned to employ more permanent staff once the resident numbers increase to seven. The registered manager is supported well by the deputy manager and team leader, each of the staff spoken with said the staff structure at the home is clear. Staff advised that the home is run well and that the residents come first. The registered and deputy manager identified that Quality assurance processes need to be addressed and hope to introduce a system of quality assurance that they believe will work well at Acorn Manor. The policies and procedures at Acorn Manor are to be reviewed; renewed and updated, the deputy manager has the responsibility for this. The pre inspection questionnaire showed that the home takes regular health and safety checks within the home and have identified what policies and procedures are not in place, this was confirmed through discussion with the deputy manager and the team leader. Reading of the homes health and safety records which show that regular checks such as; fire checks, drills and evacuations take place, that regular health and safety checks such as; the recording of fridge and freezer temperatures takes place. When reading the planned checks the inspector pointed out to the deputy manager that there had been a couple of lapses in relation to checks, for example the three hour run down of emergency lighting was one week overdue. Visual Health and Safety checks were undertaken when the home was viewed and showed 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. The deputy manager discussed the home’s recent inspection by a member of the local authority food and safety team, which identified several areas needing improvement. Improvements had been made in some areas and the Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 27 inspector was advised that work was to be undertaken to improve the remaining identified areas for improvement. See also Standard 9 and 24. The inspector found that the provision of heath and safety training was not consistent for all staff – see Standard 35. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 28 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 HOME Standard No Score 1 X 2 2 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 2 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 X X X X X X X X Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 29 NA Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 13(4)(a) Requirement 4) The registered person shall ensure that (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; Timescale for action 15/01/07 This refers to gas taps in a resident’s room that could cause a trip or fall. This refers to differences in floor levels that needs highlighting and warning signs posting 2 YA24 13(4)(b) 4) The registered person shall ensure that (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified 15/01/07 Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 30 and so far as possible eliminated. This refers to the lack of risk assessments particularly in relation to radiators being uncovered, residents using a kitchen facility unsupervised and where window restrictors are not in use. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 10 Refer to Standard YA2 YA6 YA9 YA20 YA20 YA20 YA23 YA35 Good Practice Recommendations The same level of assessment should be carried out for each prospective resident. Each resident should have an individual plan. Each resident should have individual up to date risk assessments in place. The registered manager and staff encourage and support service users to retain, administer and control their medication within a risk management framework. Medication given to residents should be signed for. Handwritten prescriptions should be written correctly as stated by The Royal Pharmaceutical Society of Great Britain. All staff should receive recognised up to date adult protection training. The home should have a staff training plan, dedicated budget and a designated person with responsibility for the training and development programme. Quality assurance processes should be in place and undertaken. The policies and procedures should cover all of the topics set out in Appendix 3 of the National Minimum Standards Care Homes for Adults (18 – 65). DS0000065498.V315304.R01.S.doc Version 5.2 Page 31 YA39 YA40 Acorn Manor 11 YA42 Routine planned safety checks should be signed for when they have been completed. Acorn Manor DS0000065498.V315304.R01.S.doc Version 5.2 Page 32 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.V315304.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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