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Inspection on 20/01/06 for Acorn Retirement Home

Also see our care home review for Acorn Retirement Home for more information

This inspection was carried out on 20th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

What has improved since the last inspection?

Locks have now been fitted to all bedroom doors and the painting to the rear of the property is now complete. There was seen to be evidence of the manager carrying out more comprehensive recruitment checks that at the time of the last inspection. There was also seen to be better documentation in respect of one resident who was at high risk of developing pressure areas.

What the care home could do better:

There is a need for staff administering medication to have accredited training in this area and input is needed in Adult Protection (to build on current staff knowledge) and infection control. More comprehensive policies and procedures in respect of the latter also need to be developed. Clearer training records that identify exactly what training gaps may be present for staff and when these will be addressed would be beneficial as would ensuring that a risk assessment is completed and discussed with the CSCI when employing staff without an enhanced disclosure. There is still a need for a manager to achieve their NVQlevel 4 in care and management and the home needs to continue to progress their quality assurance / monitoring system.

CARE HOMES FOR OLDER PEOPLE Acorn Retirement Home 102 Birmingham Road Walsall West Midlands WS1 2NJ Lead Inspector Mr Jon Potts Unannounced Inspection 20th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Acorn Retirement Home Address 102 Birmingham Road Walsall West Midlands WS1 2NJ 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) 01922 624314 01922 634549 Mr Lloyd Davies Mrs Margaret Davies Mr Lloyd Davies Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/06/05 Brief Description of the Service: Acorn retirement home is a large detached house situated in an established residential area set back from a main route close to Walsall town centre. The house overlooks school playing fields at the front with well maintained and pleasant garden to the rear. The front of the home has parking for a number of cars. The home has been adapted for provision of care to older people and has aids and adaptations consistent with the needs of this resident group. The home is owned and managed by two joint providers (one the manager and one the assistant manager). There is also a deputy manager with an established staff team consisting of care staff, cooks and cleaners. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Evidence was gathered through case tracking the care of three residents, this involving examination of all their care records and associated documentation and discussion with the residents themselves. Some policies and procedures of the home were sampled and a range of other documentation studied including staff files and other records. The inspector saw some bedrooms and communal areas of the home during the course of the day. The provider and residents are to be thanked for their ready assistance with this inspection. What the service does well: What has improved since the last inspection? What they could do better: There is a need for staff administering medication to have accredited training in this area and input is needed in Adult Protection (to build on current staff knowledge) and infection control. More comprehensive policies and procedures in respect of the latter also need to be developed. Clearer training records that identify exactly what training gaps may be present for staff and when these will be addressed would be beneficial as would ensuring that a risk assessment is completed and discussed with the CSCI when employing staff without an enhanced disclosure. There is still a need for a manager to achieve their NVQ Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 6 level 4 in care and management and the home needs to continue to progress their quality assurance / monitoring system. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above outcomes were fully assessed at the time of this inspection EVIDENCE: Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 10 Resident’s health care needs are fully met and choices as to health services used are enabled. Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Discussion with residents and records evidenced that staff enabled regular and timely access to health care services, this in accordance with the individuals wishes, for example where residents did not wish to see the dentist this wish was clearly respected. Discussion with one resident evidenced that she was able to choose the health services she used as far as this was possible, with staff taking her out in the wheelchair to her chosen optician in Walsall. There is one resident that is identified as high risk in respect of pressure areas, and there is now documentation in her case file to reflect what the home is doing in response to this risk (these practices seen to be in place at the time of the last inspection). Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 10 Staff administering medication are still in need of accredited training, the manager stating he is still trying to source this input. Residents spoken to were very clear that their privacy and dignity was respected by the staff in a variety of ways including staff always knocking on doors, showing respect for them, using their preferred names, allowing them to go to their rooms whenever wished and so on. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above outcomes were fully assessed at the time of this inspection. EVIDENCE: Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents are confident that their complaints will be listened to, taken seriously and acted upon. The home has suitable policies in place in respect of safeguarding vulnerable adults although staff training would assist to strengthen staff awareness of appropriate local procedures. EVIDENCE: The home was seen to have an appropriate complaints procedure that residents spoken to were aware of with one resident stating that the providers tried very hard to ensure that residents were satisfied. Neither the home nor the CSCI has received any complaints in the last 12 months. The home was seen to have suitable policies and procedures in place in respect of adult protection. The home still needs to provide suitable adult protection training for the staff as identified in the previous inspection report. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,26 Acorn home is a pleasant and suitable environment for older people that meets with the accommodated residents expectations, with safe and comfortable indoor and outdoor communal facilities as well as bedrooms that suit their needs. Residents have access to suitable and sufficient lavatories and equipment needed to maximise their independence. The home is clean, pleasant and hygienic. EVIDENCE: Acorn house is a traditional extended property and presents as a pleasant environment. Many rooms have high ceilings, which maximises the feeling of space within the house. Whilst the inspector did not see a forward planned programme for the on-going maintenance of the property there no critical concerns as to the condition or decorative presentation of the home from those Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 14 areas seen during the course of the inspection. The painting of the exterior woodwork has now been completed and bedrooms now have locks fitted. Residents spoken to were complementary as to the ambience and décor of the home with all stating that they were happy with the décor and the range of furniture available in their rooms. Residents are allowed to bring their own furniture in should they wish, evidence of this seen. The aids and adaptations available were seen to be consistent with the needs of the residents accommodated. The home was also seen to be clean, with no unpleasant odours detected at any point during the inspection. There was liquid soap and paper towels available in a number of toilets and the small laundry was fitted with an appropriate washing machine. The home was seen to have policies on management of MRSA and infection outbreak/management but needs to have more detailed procedures to cover infection control in its entirety. More advice in respect of this area maybe available from the infection control nurse for the area. Staff also require training in infection control. A recent inspection by the West Midlands Fire Service confirmed that all matters related to fire safety were satisfactory. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29,30 There has been improvement in the home’s recruitment practices although there is still some scope for improvement in respect of the need to risk assesses staff without enhanced disclosures. Residents are in ‘safe’ hands. Outcomes show staff to be competent and residents to feel safe although systems for the maintenance of training updates show a lack of clarity. EVIDENCE: There were some areas where staff training was identified as required at previous inspections namely in respect of medication (accredited training), adult protection and infection control. Based on the information supplied by the provider/manager there are also some others areas where some staff may require input in basic mandatory training (such as first aid and moving and handling). A training plan that identifies clearly where training input for individuals, with dates identified as appropriate where training provision is necessary should be forwarded to the CSCI for assessment. It was however pleasing to see that the home has 50 of the care staff with an NVQ level 2. Comments from residents indicated that the staff were competent and they were well looked after. Residents stated that “ if any trouble staff are there on Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 16 the spot’”, “Anything want will get”, “very seldom requests refused” and “happy with staff”. Only one member of staff has been employed since the last inspection with evidence from this staff member’s file showing all pre recruitment checks with the exception of an enhanced disclosure having been obtained. The disclosure had been applied for and there was evidence of a POVA 1st check. There was however no evidence of a risk assessment detailed why this person needed to be employed prior to receipt of a disclosure and the steps taken to reduce any potential risks (i.e. other recruitment checks and ensuring the person does not work unsupervised). All other employed staff were in receipt of enhanced disclosures. The manager is advised that any volunteers employed at the home must go through the same checks as employed staff, this including POVA 1st and enhanced disclosures. It was however pleasing to see all the new employees are been involved in the appropriate induction process, although the manager needs to consider the recent revisions made by Skills for Care. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 Overall the manager/providers run the home well, and acknowledge the views of their customers in trying to provide a service that is in accordance with their needs. Systems for quality monitoring need improvement. EVIDENCE: Comments from residents face to face indicated that there was a high degree of confidence in the people running the home and that it was felt they were offering a good service. The current provider/manager does not currently have a qualification in NVQ level 4 (including care and management), although does have extensive experience of running the home over numerous years in conjunction with qualification in related areas. There were plans to access this training but the company that was providing it has ceased trading leaving the manager in a position where he needs to find an alternative training provider. The home’s systems for quality monitoring were considered and there were seen to be methods through which the home consulted with residents and their Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 18 relatives in place, this providing a strong base for which to build on in implementing a more structured system for quality audit that would help the home identify it strengths as well as any weaknesses. It was pleasing to see that a basic annual development plan that carried reference to potential development was in place. The manager was advised that inventories of resident’s property need to be completed. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 19 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 X 2 STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 20 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. 2. Standard OP9 OP18 Regulation 13 13 Requirement To provide accredited medication training for all care staff administering medication. All staff must be trained in adult protection issues (and Walsall M.B.C. procedures related to the same). This is a repeated requirement that was to have been met by the 30.10.05. The homes policies on infection control are to be revised and expanded in accordance with professional guidance and best practice. Timescale for action 31/03/06 30/04/06 3. OP26 13, 18 30/04/06 4. OP29 13 & 19 Staff are also to be provided with training in infection control. Where staff are to be employed 20/01/06 without an enhanced disclosure the registered manager must complete a risk assessment justifying why the home needs to employ staff without disclosures and the steps taken to reduce risk to residents as far as is reasonably possible. This risk assessment must be shared with DS0000020802.V280486.R01.S.doc Version 5.1 Page 21 Acorn Retirement Home 5. OP30 18 the CSCI and agreed prior to any staff without disclosures commencing employment. A training plan that identifies any 15/03/06 gaps in the training individual staff have received, and dates by which this training is to be provided must be drawn up and submitted to the CSCI. This is a repeated requirement that was to have been met by the 30.8.05. The registered manager must have a qualification in NVQ 4 (management and care) or equivalent. This is a repeated requirement that was to have been met by the 30.10.05. To progress the development of the homes quality assurance system as discussed at the time of the inspection. This is a repeated requirement that was to have been met by the 30.11.05. Resident’s property is to be recorded within an inventory. 8. OP31 9 31/03/06 9. OP33 24 31/05/06 9. OP35 13 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP36 Good Practice Recommendations To provide clearer evidence that the staff are being formally supervised on a one to one basis at least six times annually. Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acorn Retirement Home DS0000020802.V280486.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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