Inspection on 29/01/07 for Acorn Retirement Home

This inspection was carried out on 29th January 2007.

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.

Other inspections for this house

Acorn Retirement Home 06/02/09

Acorn Retirement Home 06/02/08

Acorn Retirement Home 20/01/06

Acorn Retirement Home 16/06/05

Acorn Retirement Home 01/03/05

Acorn Retirement Home 17/09/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Acorn Retirement Home 102 Birmingham Road Walsall West Midlands WS1 2NJ Lead Inspector Ms Maggie Bennett Key Unannounced Inspection 29th January 2007 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.V326965.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 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.V326965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th January 2006 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. Fees charged range from £327.15 to £400.00 per week. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on a weekday between 9.30 a.m. and 7.00 p.m. Prior to the inspection a Pre Inspection Questionnaire was completed by the Registered Manager and returned to the Commission. In addition 11 of the service users completed anonymous surveys and these were also returned to the Commission. During the course of the inspection several service users were spoken to, both in groups and as individuals. 2 members of staff were interviewed and discussion took place throughout the day with the Registered Manager/Provider. The care plans of 4 service users were looked at in detail in order to inspect assessment and care planning practice. The medication administration was checked and records were seen of the social care activities provided for the service users. The lunchtime meal was taken with the service users and the kitchen was inspected. A tour took place of the building, including all the communal areas and some bedrooms. 4 staff files were seen in order to assess recruitment procedures and to inspect for evidence of satisfactory staff training. Various documents were seen for evidence of health and safety checks. All the key standards of the National Minimum Standards were inspected on this occasion. What the service does well: Acorn Retirement Home provides good care for its service users in a warm, homely and comfortable environment. One of the main aims of the Registered Manager and staff is to provide a “home” and this is achieved as far as possible, with service users’ individual aspirations and preferences being of paramount importance to the very caring staff team. Both in their returned questionnaires and during the inspection the service users spoke highly of the care they received. Here are some of the things they said of the staff: “Very kind and caring.” “All are very good.” “We can’t fault the staff, they have a good approach.” “Management and staff are always very attentive, caring and thoughtful. Nothing is too much trouble.” “Staff are always available to speak to – and responsive.” “I would like to say how kind and helpful the staff are to me at all times.” Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 6 There are good assessment processes in place, with all prospective service users being given the opportunity to spend time at the home before making any decision. All service users have a care plan, so that staff are aware of the individual service user’s personal, health and social care needs. Healthcare needs are well met and service users feel confident that professional healthcare assistance will be sought when needed. Service users feel that they are very much respected at the home and that their rights to privacy are upheld. The routines of the home are flexible and can be changed to meet individual needs. Service users say that their family and friends are made to feel welcome and can visit at any time. There are good procedures in place to deal with any concerns that service users might have and service users spoken to felt that they were listened to and that their concerns were acted upon. The home is a very pleasant place to live, it is tastefully decorated and there are good standards of hygiene, service users confirming that it is always clean and fresh. There is a very experienced Registered Manager/Provider and management team at the home and service users feel that they are in safe hands. What has improved since the last inspection? What they could do better: All service users have a care plan in place, but these must be reviewed on a monthly basis, preferably with the service user. Notes of the review meeting must be kept and care plans updated to reflect any changing needs. There are several areas where medication administration needs to be improved so that service users are fully protected. Robust policies and procedures need to be put into place in accordance with current legislation and guidance. The system of administration of medicines observed at the inspection must improve so that all medicines can be safely stored in the event of an emergency. The practice Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 7 of walking around the home with a medicine tot for each individual service user must cease. The person administering the medication must sign the administration record chart immediately after the medicine has been given. All staff who administer medication must receive suitable accredited training. (For further details see Standard 9 and Statutory Requirements). The home’s Adult Protection Procedures must be updated and staff must be trained in Adult Protection issues. (It is understood that this training is currently being sought). The home needs to develop a training plan for the staff that identifies any gaps in the training individual staff have received. Although the home is clearly well managed, there is still a requirement for Acorn to have a manager who is qualified to NVQ4 in care and management. The home needs to improve the way it obtains the views of its service users and to make progress with a quality assurance/quality 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. The summary of this inspection report can be made available in other formats on request. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 8 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.V326965.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 is not applicable as the home does not provide intermediate care. Quality in this outcome area is good. Service users are given the opportunity to spend time at the home prior to making any decision. A thorough assessment takes place so that both the service user and staff can be assured that the home will be able to meet the person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The assessment information of 3 service users was seen during the day in order to inspect the home’s assessment procedures and practice. Where service users are admitted through Care Management arrangements a Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 10 Summary of the Care Management Assessment is received by the home prior to the person’s admission and evidence of this was seen during the inspection. In the case of service users who are self-funding, the Registered Manager or Deputy Manager carry out an initial assessment and information is gathered from the service user and their family. The main assessment, however, takes place at the home, when the prospective service user is invited to spend time at Acorn, usually having either lunch or tea with the other service users. In their returned surveys all the service users said that they had received enough information about the home prior to making a decision. One person said: “I had a very well organised visit on the previous week, which even included transport home and my tea.” During the day’s visit, all those areas listed in Standard 3.3 are assessed and staff at the home complete a written assessment document. These documents were seen at the inspection. The information obtained at the assessment is used to develop a plan of care. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. Each service user has a plan of care so that staff are aware of the individual’s personal, health and social care needs. Care plans are reviewed, but service users need to be given more opportunities to be involved in the review and updating of the plans. The healthcare needs of the service users are well met at the home and service users feel confident that professional healthcare assistance and advice will be sought when needed. Medication records are accurate and up to date. Some of the processes with regard to medication administration currently operating at the home are not in line with professional guidance and could place service users at risk. Staff who administer medication have received some training, but further in depth training is needed. Service users confirm that they are respected by the staff and that their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 12 Three service users’ plans of care were seen in order to assess the home’s processes and practice with regard to ensuring that the personal, health and social care needs of the service users are met. A plan of care had been developed for each person. Currently all the plans are filed together. It is recommended that all service users have separate files, both for ease of access to information and to ensure compliance with the Data Protection Act. All the plans seen contained a risk assessment, including a falls risk assessment. Not all sections of the risk assessment had been completed in some cases. Although there was space for a service user signature on the care plan, these had not been signed or dated on any of the files seen. In some cases the care plan was undated. The Registered Manager reviews the care plans, including the risk assessments on a monthly basis. At present, however, there are no notes following the review, just a signature confirming that the review has taken place. It is recommended that reviews are undertaken with the service user and that notes are made following each review, which are signed by the service user if appropriate. In their returned surveys and during conversation at the inspection, service users confirmed that their health care needs were well met at Acorn. Healthcare needs are documented within the care plan, which includes a pressure sore risk assessment and a nutritional screening tool. It was noted that daily notes recorded that the District Nurse had called to dress a pressure sore for a service user. This could be cross-referenced to the care plan, which stated that the skin on the service user’s buttock was broken. Pressure relieving equipment, such as mattresses and cushions are provided by the District Nurses where needed. The Continence Promotion Nurse visits on a regular basis. A number of service users come from the local area and keep their G.P.s. There are a variety of G.P. Practices locally. The NHS Chiropodist visits regularly and some service users choose to have a private Chiropodist. A dentist and optician visit the home. Although Acorn does have policies and procedures in place for the receipt, recording, storage, handling, administration and disposal of medicines, these need to be reviewed and updated as necessary so that they are in line with “The Administration and Control of Medicines in Care Homes and Children’s Homes” document and medication guidance provided by the Commission. This is necessary because it was found at the inspection that potentially unsafe procedures have been adopted at Acorn and that practice needs to be changed. The home uses the Boots Monitored Dosage system for the administration of medication. None of the current service users take charge of their own medicines, apart from some creams. The home must keep a list of specimen signatures of staff who administer medication so that they can identify which Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 13 members of staff have signed the Medication Administration Record Chart. At the time of the inspection staff were dispensing medication from the original container into a tot in the medication room. They were then taking the individual tots to the service users (either to their rooms or to the table) and leaving the medication for the service user to take. The administration record sheets were being signed for all service users at the same time. This is very poor practice and could potentially place service users at risk. Medication must not be removed from the original container until the time of administration. When medicines are transported around the home, they must be done so in a secure manner. The person administering the medicines must sign the administration record immediately after the medicine has been given. If MAR charts need to be altered following instruction from the G.P. or Pharmacist, this should be done by crossing out the original instruction and writing the new instruction in ink. Instructions should not be written in pencil. The new instruction should be signed and dated, preferably by the G.P. or Pharmacist. Controlled drugs (including temazepam) must be kept in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973 as amended. This specifies the quality, construction, method of fixing and lock and key for the cupboard. A separate record must be kept of the receipt, administration and disposal of controlled drugs. These records must be kept in a bound book or register with numbered pages. The bound book will include the balance remaining for each product with a separate record page being maintained for each service user. Staff who administer medication have received one day training in medication administration. Although this training is of benefit (and is accredited), it is unlikely to meet the “Level 2” standard as set out by Skills for Care. The home must access suitable Level 2 training. Information on this can be obtained through local Colleges or the Regional Office of Skills for Care. In the meantime further training is to be provided by the home’s Pharmacist. The Registered Manager must also establish a formal means to assess whether the carers who administer medication are sufficiently competent before being allowed to give medicines. This process must be recorded in the care worker’s file. The majority of service users have a single room at Acorn and therefore all personal care giving takes place in private. Double rooms are provided with screens. Portable telephones are provided so that service users can make and receive calls in their rooms if they wish. During the course of the day staff were observed to be treating service users with respect and upholding their right to privacy. Service users spoken to said that staff treated them respectfully and always knocked before entering their rooms. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. The routines of daily living are flexible and can be changed to meet individual service users’ needs. A number of activities take place at Acorn, which offer the service users opportunities for stimulation through social and leisure events. Family and friends are made to feel welcome and can visit at any time. The food provided is of good quality and choices are always available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection service users confirmed that the routines of the home are flexible and that they are able to make choices in their daily lives. One person stated that she was very pleased she was able to eat in privacy in her own room. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 15 Service users confirmed that social and leisure activities are provided at Acorn and that they are free to choose whether or not to join in. It was observed that service users’ interests and hobbies are noted at assessment and that a record is made of any activity that the service user takes part in. Each afternoon a member of staff is delegated to be responsible for providing an activity. The type of activity is left to the discretion of the member of staff, who consults with the service users. Recent activities at the home have included: quizzes, crosswords, horoscopes and light exercise sessions. A number of entertainers visit the home. Recently service users and staff took part in the RSPB “Bird Watch” day. Outside trips are held, including the monthly concert given by the Senior Citizens’ Orchestra at Walsall Town Hall. Before Christmas service users went to Fosters’ Garden Centre, where they had tea. A monthly service is provided by a representative from St. Matthew’s Church. Special services are held to celebrate festivals, such as Christmas, Easter and Harvest. Visitors are welcome at any time and service users spoken to confirmed that their relatives visited frequently and that they often went out with them. They also said that their relatives were always made to feel welcome and were offered tea and biscuits. Service users are able to bring personal possessions with them and one service user expressed satisfaction that small items of furniture had fitted well in her room. The majority of service users said that they were very satisfied with the quality of food provided. Several said that if they did not like what was on the menu for the main meal they would always be offered an alternative. Menus indicated that 3 full meals are offered each day, in addition to drinks and snacks throughout the day and supper in the evening. One person said that staff would always provide her with a sandwich at any reasonable time during the day or evening. A cooked breakfast is not provided at present, which is the service users’ choice. Special therapeutic, religious or cultural dietary needs can be catered for, although none are requested at present. The meal served at the time of the inspection was tinned salmon with hollandaise sauce, broccoli, green beans and mashed potato, followed by peaches and cream. The kitchen was seen during the inspection and was found to be in good order. The home has won a Clean Premises Award for the past 3 years. Evidence was seen of the regular checking of fridge, freezer and cooked food temperatures. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is adequate. Service users are confident that any concerns or complaints they have will be listened to, taken seriously and acted upon. There is a policy and procedure in place with regard to Adult Protection, but this needs to be updated to ensure that it is in line with the local Social Services policy and the Department of Health guidance, “No Secrets”. Although the protection of the service users is of paramount importance at the home, all staff require training in this area so that they are clear of their responsibilities and the correct process to follow if there is an allegation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Complaints Procedure in place, a copy of which is given to service users and their relatives. Both in their returned surveys and in person service users said that they would know who to speak to if they wished to make a complaint. They also felt that they would be listened to. It is recommended that the Complaints Procedure be further developed to include timescales for dealing with the complaint. No complaints have been received by the home, or by the Commission, since the last inspection. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 17 The home does have an Adult Protection Procedure in place, but this is not in line with the local Social Services Procedure or the Department of Health document, “No Secrets”. The Deputy Manager is currently working on the procedure and a new document is to be produced shortly. As at the last inspection, staff have not received specific training in Adult Protection. The Registered Manager states that this is currently being arranged. This is an outstanding requirement from the last 2 inspections. It is essential that staff are aware of their responsibilities under the Protection of Vulnerable Adults Guidance and that proper procedures are followed in the event of any allegation. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. Acorn Retirement Home is homely, warm and comfortable and provides a safe and attractive environment in which to live. There are good standards of hygiene and service users confirm that the home is always fresh and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Acorn Retirement Home is conveniently situated on the Birmingham Road in Walsall. It is an older style property, which has been converted to provide very comfortable and homely accommodation. There are 14 single rooms, 10 of which have an en suite bathroom, and 2 double rooms, 1 of which has an en Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 19 suite facility. All the communal areas of the home were seen during the inspection, including the toilets and bathrooms. Several of the service users’ rooms were also seen. The home was found to be clean, warm and comfortable and to meet the needs of the service users. Service users spoken to were very pleased with their rooms, which several had personalised to suit their individual taste. Some had brought small items of furniture from home. There is no written plan of maintenance in place, but the Registered Persons arrange redecoration and refurbishment as needed and there are no concerns with regard to the presentation of the home, which was found to be clean and pleasant. There is a very attractive and well-tended garden to the rear of the property, which is much enjoyed in the summer months. In their returned surveys, service users said that the home was “always” fresh and clean and this was confirmed during the inspection. The laundry was found to be in order. There is no sluice facility in the home at the moment and it is recommended that when the washing machine needs to be replaced, a machine with a sluice programme be purchased. There are policies and procedures in place with regard to the control of infection. Staff have not yet taken part in infection control training and this needs to be arranged as a matter of urgency (see Standard 38). It is strongly recommended that bar soap and nail brushes be removed from the communal bathrooms and toilets. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28,29 and 30. Quality in this outcome area is good. Sufficient staff are on duty to meet the needs of the service users. Service users have confidence in the staff and feel that they are well cared for. There are sound recruitment procedures in place, which protect the service users. The Registered Manager recognises the importance of staff training, but there are still some areas which need attention (see also Standard 38). This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas seen during the inspection show that there are sufficient staff on duty to meet the needs of the current group of service users. The Registered Manager states that he has assessed the dependency levels of the service users and uses this information plus the Residential Forum Guidance to ascertain the staffing levels required. There are 3 care staff on morning and afternoon shifts, 2 care staff during the evening and 2 care staff on duty overnight. The Manager and Deputy Manager are Supernumerary and either they, or a senior member of care staff is always On Call in the event of an emergency. Sufficient ancillary staff are employed. In their returned surveys, Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 21 the majority of service users stated that staff were “always” available when they needed them. One person said: “I know they will come if I ring my bell.” Staff are making good progress with their NVQ training and at the time of the inspection 58 had already achieved the qualification. The files of 2 recently recruited staff were seen in order to assess the home’s recruitment practice. Both contained an application form. It is recommended that the home review this form so that there is enough space for a full employment history. Currently the Registered Manager states that this is obtained at interview. The files each contained 2 written references and evidence of satisfactory Criminal Records Bureau and Protection of Vulnerable Adults checks. All staff are given copies of the General Social Care Council Code of Conduct. Currently there is no staff training and development programme in place and staff files do not contain an individual training assessment and profile. Both of these documents must be developed. At present the Registered Manager is consulting with the West Midlands Care Association, who are hoping to arrange a training programme. Staff files seen at the inspection show that the majority of staff have taken part in the mandatory training areas of fire safety, moving and handling, first aid and food hygiene, but that several now require refresher training in these areas (see also Standard 38). The file of a recently recruited member of staff was seen and this contained evidence of satisfactory induction training. A recently recruited member of staff described her induction period stating that the training was thorough and carried on over a 3 week period “until I felt confident”. All staff receive at least 3 days paid training per year. There is a loyal and stable staff group at Acorn, several of whom have worked at the home for a number of years. The members of staff spoken to at the inspection were enthusiastic and felt that they were well supported by the management team at the home. One member of staff said: “I think it’s a brilliant home – it’s great.” Service users spoke highly of the staff. Some made comments in their surveys, while others spoke during the inspection. They said: “Very kind and caring.” “All are very good.” “We can’t fault the staff, they have a good approach.” “Management and staff are always very attentive, caring and thoughtful. Nothing is too much trouble.” “Staff are always available to speak to – and responsive.” “I would like to say how kind and helpful the staff are to me at all times.” Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 22 Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. The Registered Manager and management team are highly competent and experienced and service users feel that they are in safe hands. To date the Manager has not taken part in the Registered Managers’ Award Training or NVQ4 Award. Service users feel that their views are listened to and acted upon. The home has yet to develop a formal Quality Assurance and Quality Monitoring system. Service users’ monies are kept securely and appropriate records are maintained. Some staff need up to date training in the mandatory areas of fire, moving and handling, first aid and food hygiene. All staff need training in infection control. This training is needed in order to protect the service users. There are generally good policies and procedures in place to protect the health and safety of service users and staff. This judgement has been made using available evidence including a visit to this service. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager has owned and managed the home for over 20 years and is highly regarded by the service users and staff and is also very experienced. Both the Assistant Manager and Deputy Manager have also worked at the home since it opened in 1986. Service users feel in very safe hands with the management team, who they feel are always approachable and caring. The Manager does not hold the Registered Managers’ Award or the NVQ4 qualification. It was the intention that the Deputy Manager would undertake this training, but unfortunately the Company engaged to carry out the training ceased trading. The Manager hopes that this training can be resumed with another training provider in the near future. There are clear lines of accountability within the home. Acorn seek the views of their service users through informal discussion with staff and management. Service users’ meetings are not taking place. The Registered Manager feels that meetings could create an “institutionalised” feel to Acorn, which he is anxious to maintain as a home. Service users spoken to feel that their views are listened to and acted upon. There is, however, no formal Quality Assurance and Quality Monitoring system in place at present. The Registered Manager states that such a system is being explored through the West Midlands Care Association and it is hoped that this will be developed in the near future. The majority of service users either look after their own monies or this is taken care of by their families. A small number of service users request that the home take charge of a small “float” on their behalf. The monies are kept securely and appropriate records are retained. A sample of the monies and accompanying records were seen at the inspection and there were no discrepancies. As stated in Standard 30 (above) some staff require updated training in the areas of moving and handling, fire safety, first aid and food hygiene. Staff must also receive training in infection control. Records seen at the home show that fire alarms, the emergency lighting system and fire drills take place at the required intervals. The home has a Fire Risk Assessment in place and the Registered Manager states that this has been approved by the Fire Officer. The Registered Manager is recommended to take part in the West Midlands Fire Service training for managers. All hazardous substances are stored securely and some staff have taken part in COSHH Awareness training. Evidence was seen of the regular testing and maintenance of the gas system, the lift, the electrical system and all electrical appliances. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 25 There is an unused hoist in one of the communal bathrooms, which is to be removed. The home must ensure that the water system is regularly checked for evidence of legionella and appropriate action taken to disinfect the water system. Water temperatures at outlets accessible to service users are taken regularly and recorded. Any accidents, injuries and incidents of illness or communicable disease are recorded and reported to the Commission. Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation Requirement Timescale for action 28/02/07 2. OP9 3. OP9 4. OP9 15(2)(b)(c Care plans must be reviewed at ) least once a month and updated to reflect changing needs. (Plans were signed to say that they had been reviewed, but there but there were no notes to verify this or any changes noted to care plans following reviews). 13(2) The home must ensure that they have a robust policy and procedures in place for the receipt, storage, administration and recording of medication and that staff adhere to these procedures. 13(2) The home must keep a copy of the specimen signatures of staff who administer medication so that they can identify which members of staff have signed the Medication Administration Record Chart. 13(2) The system of administration of medicines must improve so all medicines can be safely stored in the event of an emergency. The practice of walking around the home with a medicine tot containing medicines must DS0000020802.V326965.R01.S.doc 28/02/07 16/02/07 29/01/07 Acorn Retirement Home Version 5.2 Page 28 5. OP9 13(2) 6. 7. OP9 OP9 13(2) 13(2) cease. The person administering the medication must sign the administration record chart immediately after the medicine has been given. Any handwritten instructions on MAR charts must be written in ink, signed and dated. Controlled drugs must be stored in a cupboard meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973. A separate record must be kept of the receipt, administration and disposal of controlled drugs. These records must be kept in a bound book or register with numbered pages. Staff who administer medication must receive suitable accredited training. The Registered Manager must establish a formal means to assess whether the carers who administer medication are sufficiently competent before being allowed to give medicines. This process must be recorded in the care worker’s files. The home’s Adult Protection Procedure must be in line with the local Social Services Procedure and the Department of Health guidance “No Secrets”. All staff must be trained in adult protection issues. (Previous timescales of 30/10/05 and 30/04/06 not met). The Registered Manager must develop a training plan that identifies any gaps in the DS0000020802.V326965.R01.S.doc 29/01/07 29/01/07 28/02/07 8. OP9 13(2) 31/03/07 9. OP18 13 30/04/07 10. OP30 18 30/04/07 Acorn Retirement Home Version 5.2 Page 29 training individual staff have received. Dates by which this training is to be provided must be drawn up and submitted to the CSCI. (Previous timescales of 30/08/05 and 15/03/06 not met). Each member of staff must have an individual training assessment and profile. The Registered Manager must 31/07/07 have a qualification in NVQ 4 (management and care) or equivalent. (Previous timescales of 30/10/05 and 31/03/06 not met). The home must develop a quality 31/07/07 assurance system. (It is understood that this is in progress in conjunction with the West Midlands Care Association). (Previous requirements of 30/11/05 and 31/05/06 not met). All staff must have up to date training in moving and handling, first aid, fire safety and food hygiene. Staff must receive training in infection control. The water system must be regularly tested for legionella and, if required, the system disinfected. 11. OP31 9 12. OP33 24 13. OP38 18(1)(a) 13 31/05/07 14. OP38 13(3) 31/03/07 Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that all service users have separate files for their care plans, both for ease of access to information and to ensure compliance with the Data Protection Act. It is recommended that service users be invited to sign their care plans. It is recommended that care plan reviews are undertaken with the service user and that the notes taken at the review are signed by the service user, if appropriate. It is recommended that the Complaints Procedure be further developed to included timescales for dealing with any complaint. It is recommended that the Registered Manager attend the Manager’s training course run by the West Midlands Fire Service. 2. 3. 4. 5. OP7 OP7 OP16 OP38 Acorn Retirement Home DS0000020802.V326965.R01.S.doc Version 5.2 Page 31 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: 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. 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