Inspection on 06/02/08 for Acorn Retirement Home

This inspection was carried out on 6th February 2008.

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

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 29/01/07

Acorn Retirement Home 20/01/06

Acorn Retirement Home 16/06/05

Acorn Retirement Home 01/03/05

Acorn Retirement Home 17/09/04

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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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Acorn Retirement Home 102 Birmingham Road Walsall West Midlands WS1 2NJ Lead Inspector Joan Franklin Key Unannounced Inspection 6th February 2008 09:00 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.V345214.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.V345214.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.V345214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 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 £337.29 to £405.00 per week. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further practice. One inspector undertook the fieldwork visit to the home on one day. The registered manager assisted us throughout. The home did not know that there would be a visit on that day. There were 18 people living at the home and one person attends for day care on the day of the inspection. All of the people living in the home are ladies. Information was gathered from speaking to and observing people who lived at the home. Two people were “case tracked”. This involves discovering their experiences of living at the home by looking at the care plan, the medication record and other recording systems kept in the home as well as speaking to people and reviewing activities in the home to focus on outcomes. Case tracking helps us to understand the experiences of people who live in the home. Staff files, training records, and health and safety records were also reviewed. Random questionnaires were sent out in order to gain people’s views of the home. Two people who live at the home returned the questionnaires. These contained positive comments about the service and these are included in the report. Seven people who live at the home, three members of staff, the continence advisor nurse, the domiciliary hairdresser and one family member spoke to us to provide their views. Prior to the inspection the registered manager had completed an Annual Quality Assurance Assessment (AQAA) which was available on the day of the visit. This gave information about the home, staff and improvement plans for the future. Details from the AQQA and the service history which is information about the home since the last inspection have been taken into consideration. No immediate requirements were made at the time of this visit. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The storage and administration of medication has improved. The home has altered the pharmacy, which provides services to the home. This also enabled training on medication to be provided to staff. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 7 The home has made use of training provided by the Local Authority for staff to attend training on awareness of elder abuse. Attention has been given to providing suitable cleaning products in the toilets and bathrooms. A member of staff has responsibility for finding out the views of all the people who live there to improve quality assurance in the home. The policy on adult protection has been brought up-to-date with details of the procedures of the local authority, which is necessary to ensure that the home responds appropriately to any concerns of abuse. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Acorn Retirement Home DS0000020802.V345214.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.V345214.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): 3 and 6 Quality in this outcome area is excellent. Both people wishing to live in the home 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 manager told us that all those people and their family and friends who are considering an admission have an opportunity to spend time prior to a possible admission. The daughter of a lady who has recently decided to live at the home confirmed that this visit was offered. The daughter also confirmed that there was a full assessment to ensure that suitable care would be provided for her mother. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 10 The majority of people living at the home are self-funding. This means that the manager and the deputy manager are responsible for the pre-admission assessments together with the person and family or friends. A care plan was seen which gave details of an assessment. The manager uses the Statement of Purpose to display most of the policies of the home resulting in two volumes, which are available in the entrance hall for visitors to read. The contents do need reviewing to ensure that the information is current and accessible for readers. The home has a brochure for people to read about the services available to help with decisions about a possible admission. People told us: “The assessment went well”. “Received enough information before I moved in”. Acorn Retirement Home DS0000020802.V345214.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): 7,8 9 and 10 Quality in this outcome area is good The healthcare needs of the people who live there are well met and they feel confident that professional healthcare and advice will be sought when required. Care planning should be improved to ensure that the people using the service are involved and consulted and that the staff have the information required to meet their changing needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has now acquired a medicine trolley. This has stopped the previous practice of dispensing medicines from the original container into a tot as the medication is in blister packs for dispensing to each person at the relevant time of day. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 12 The home has changed the pharmacy provider. The manager and the deputy manager and a member of staff reported that the service from the new pharmacist is an improvement for dispensing and advice. The manager provided details of the training programme, which staff have now received. The home must still obtain a book for recording controlled drugs, but there is now a locked cupboard for controlled drugs. There are two copies of the list of signatures of staff who dispense medication. The manager and the deputy manager have improved the systems since our last visit including an inspection by the pharmacy inspector to establish a robust policy and procedure for the receipt, storage, administration and recording of medications. The information that was seen suggests that staff are now following most of the procedures. The details on the medication administration records (MAR) charts were current though some information was still written in pencil. The recommendation that details be written in ink remains. None of the people who live at the home administer their own medication. The home administers medicine to the person who receives day care. The care plans are now separated. The monthly review procedure consists mainly of the signature of the manager with no details of involvement of the person who lives there or a member of the family or a friend. The recommendation from the last inspection remains that details are kept that the review has included the person who lives there or a member of the family. As the majority of people are self-funding there are few reviews lead by the Local Authority. A revised reviewing system would show that the people who live there or their families are involved in the process. On the day of this visit, one lady was being taken for a hospital appointment. Details were written on to the daily records, which were kept in a card index box, which was rather dilapidated. The staff rely on this box as the main source of information about what is happening with people who live there and what tasks must be done. The system appears to work although the contents were not in a recommended condition. There is not an obvious system as to how the details in the daily records are transferred to the review process to assist those who are involved to show that the needs of each person is receiving attention. The Annual Quality Assurance Assessment (AQAA) does not include an improvement plan for the reviewing care plans system. The manager said that one person is receiving treatment for pressure sores sustained during a two weeks stay in hospital. The treatment plan was not seen. The home has instructions in the kitchen for the special food needs o0f people who live there. This enables people to have food and nutrition suitable for their health needs. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 13 The continence advisor nurse was at the home during our visit. She said that home always calls for the nurse advisor as soon as there are signs of problems with continence. She said that advice about continence is followed to help people who live there have the minimum of discomfort. She considers that the toilet facilities cater for the people’s needs. During the visit we observed that there was respect for the people who live there to provide dignity and to take suitable interest in the circumstances of each person. People who live there told us: “ I am given a paracetomol when I ask for one”. “Pleased that my mother is taking her drugs at the right time and that the home has consulted a GP and responded to the changes to the prescribed medication”. “The carers have a nice approach and take into account the choice of the person who lives there. They always knock on the door before entering”. “My food is mashed up for me”. Acorn Retirement Home DS0000020802.V345214.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): 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 the individual preferences of the people who live there. A number of activities are provided and family and friends are made to feel welcome and can visit at any time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit people who live there confirmed that the routines of the home are flexible and that they are able to make choices in their daily lives. In the afternoon several of the ladies chose to spend the time in their rooms where they were following a variety of interests ranging from flower arranging to reading poetry to watching television. The manager said that since the autumn no one has wanted to go to the concerts at the Walsall Town Hall. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 15 A reply to the “Have your say about” questionnaire appreciated communion given at the home. People who live in the home say that they enjoy their meals. The kitchen was seen during the visit. The member of staff was preparing tea. She said that she enjoys preparing food in particular for the individual preferences of the people who live there. The deputy manager said that the home aims to know what each person likes at the same time as attending to nutritional needs. At the time of the visit the domiciliary hairdresser made her weekly visit. This was quite a lively occasion with ladies walking in and out of the dining room converted to a hair salon. There was a free and easy conversation about all sorts of topics. The people who live in the home who were having their hair done were ready to talk to us about their life in the home. The hairdresser has insurance liability but she does not have a CRB check. She has been providing a hairdressing service for 20 years. She commented that she considers that suitable care is provided to the ladies who she knows from doing their hair. During the visit people who live there and a relative said that there is an open policy for visiting and that they are assisted with going out to events, which are important to them. This enables people to chose their activities and maintain contact with their family and friends as they wish. People told us: “It is convenient for family to visit”. “The visiting policy is very relaxed”. “I’m always asked to join but prefer my own company in my room”. “I always enjoy the meals” was the comment in the reply to 2 questionnaires. Acorn Retirement Home DS0000020802.V345214.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): 16 and 18 Quality in this outcome area is adequate. People who live at the home are confident that any concerns or complaints they have will be listened to, taken seriously and acted upon. The staff have received training on Adult Protection but the home must ensure that all of the staff working in the Home are checked appropriately to fully safeguard people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have not received any complaints since the last inspection. The home does have a Complaints Policy, which is readily available to the people who live there and to family and friends. The replies in the questionnaires confirmed that people know how to make a complaint and a family member said that she knew how to raise any concerns. A member of staff said that she was sure that she could easily raise any matter that she considered was not satisfactory. Staff have received training on Abuse Awareness provided by Walsall council. The manager and two members of staff said that they had found this training useful to assist with protecting the people who live in the home. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 17 During the tour of not premises a drawer was seen to be broken. The manager told us that he has a volunteer who is doing some gardening and odd jobs at present, as the handyman is on long term sick leave. The policy for volunteers being involved in activities does not meet the requirements for the protection of vulnerable adults and does not comply with employment regulations for volunteers working in a registered home. There is a requirement that the registered provider does not use the volunteer until the necessary pre-employment information is available. This requirement is necessary to contribute to all of the procedures to ensure the safety and protection of the people who live there. The home does now include the Multi Agency Guidelines form the Local Authority, which was required at the last inspection. This improves the procedures for the protection of the people who live in the home. The manager said that there have been no complaints. He has allocated a task to a new member of staff to ask all of the people who live there if they have any suggestions to improve systems as part of the Quality Assurance for the home. People told us: “If I’m not happy about something I talk it over with others and then talk to the manager. I know about CSCI”. Acorn Retirement Home DS0000020802.V345214.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): 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the time of our visit several visitors called at the home. The visitors told us that they usually found the home clean and pleasant. The manager said that he is expecting to be awarded this year, the same as previous years, a “Clean Premise Award” from Environmental Health. Our tour of the premises showed that the bedrooms and the communal areas are well kept and comfortable. There are paper towels and liquid soap in the bathrooms. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 19 Clothes and bed linen are washed and well presented in the laundry. The washing machines have not been replaced since the last inspection. The manager said that when it is time to replace them he intends to follow the recommendation to buy machines with a sluice facility to maintain the cleanliness and presentation of the people who live there. The home does not have a maintenance plan to show that there are plans to replace items, which are wearing out, such as the extractors in the kitchen. The handyman is currently off sick. There is not a suitable replacement for the maintenance jobs around the home. People told us: “The toilets are appropriate for the people who live in the home”. “There is a good atmosphere in the home”. The replies from two questionnaires said, “The home is always fresh and clean”. “I like being in the front to look out of the window”. Acorn Retirement Home DS0000020802.V345214.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): 27, 28, 29 and 30 Quality in this outcome area is good. Sufficient staff are on duty to meet the needs of people who live there, but the sound recruitment policies followed to recruit permanent staff are not extended to volunteers, which compromises the safety of the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager told us that there continue to be sufficient staff on duty to meet the needs of the current group of people who live there. A member of staff said that she considers that the staff group works together well and that it is easy to raise any concerns. She said that there is an effective communication system between staff to provide continuity of care. Since the last inspection there has only been one change in permanent members of staff. The staff record shows that recruitment procedures have been followed. A volunteer has started to do some maintenance work around the home including some gardening tasks without complying with pre-employment procedures. This must cease. No volunteers should do any work until there Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 21 are positive employment checks to ensure the safety of the people who live there. Staff have received training on administering medicines and abuse awareness. A plan of staff training and plans for the future was provided to us including the training needs of each member of staff. The recently recruited member of staff commented that the induction programme was appropriate and that she moved on to foundation training to make her aware of adult protection procedures in a suitable way. This member of staff has been given responsibility for a project to improve quality assurance in the home. The details seen by us show that the emphasis is to spend time with each person living in the home to give them an opportunity to talk about any ideas they might have to change some things, which happen in the home. The manger is overseeing the project to put into practice where possible the ideas from people who live in the home. The intention is for staff to be competent to respond to the needs of people who live there. One member of staff said that she thinks that it would be useful and appropriate to have training on dementia. She said that she has read a little about the subject at the library. People told us: “Everything is well looked after. Everyone is kind and helpful”. “My work is about building relationships to get to know what people would like to say”. “I like living here”. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 22 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): 31, 33, 35 and 38 Quality in this outcome area is adequate. The registered manager and the management team are experienced and competent. People who live there feel they are in safe hands. There are generally good policies and procedures in place to protect the health and safety of people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has owned and managed the home for over twenty years. He is highly regarded by people who live there and by staff. The Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 23 deputy manager and the assistant manager have also worked in the home since it opened in 1986. We were told at this visit that the deputy manager is going to attend the level 4 NVQ Registered Manager’s Training Award programme this year. The manager gave details of the research undertaken to provide the required training to staff. The manager said that this has included starting a programme at a local college for a course on medication. The college proved unreliable. The manager persevered to ensure this course was provided by a pharmacy. The certificates of attendance were seen during the visit. There were also certificates of attendance for elder abuse awareness provided by the Local Authority. The manager has arranged staff training to promote the safety and protection of the people who live there. The manager said that consideration would be given to providing training about dementia. The home ensures that the any monies belonging to people are kept securely. Family or friends of people manage the finances of all the people who live in the home. All hazardous substances are stored securely in line with COSHH. We saw the service checks for the lift and for the gas and for the electrical equipment. The most recent fire inspection was on the 18th December 2007. The Local Authority has provided an audit of infection control, which recommends some improvements though the home is considered to have a good standard of infection control. The manager said that he has taken advice about testing the water system for legionella. The manager has decided that testing is not necessary following advice from an environmental health specialist as this is a usual domestic system. The home keeps records of the safety checks, which should be completed and makes use of initiatives for the safety of people. Information was seen at this visit about supervision arrangements of staff. The manager does have a formal arrangement to supervise staff but this is not as frequent as the expected frequency of six times a year. Staff told us that it is always easy to speak to the manager. The manager should have formal recording of supervision sessions to provide evidence that the home is interested in the health and welfare of staff. The manager said that the home aims to value diversity to the people who live there and to staff. At this time all of the people using the service are ladies. The manager said that services could be provided if any male or men wanted to progress with an admission. All of the staff are currently women of different ethnic heritages. The manager said that he considers that the equal Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 24 opportunities policy is effective to respond to the needs of the people who live there and to staff. The manager has instigated a project to develop a more comprehensive Quality Assurance programme. This is to continue to show that the home is run in the best interest of the people who live there. Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 25 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 4 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 27 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) (c) Requirement 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). This will ensure that the staff have the information needed to respond to peoples changing needs. Previous timescale of 30-102005 not met 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. This will ensure that people using the service are given the appropriate medication at the correct time. Previous timescale of 28/02/07 not met 3. OP29 19 The policy for the involvement of volunteers must follow the same requirements for preemployment checks as for permanent staff. This will ensure DS0000020802.V345214.R01.S.doc Timescale for action 01/04/08 2. OP9 13(2) 01/04/08 01/04/08 Acorn Retirement Home Version 5.2 Page 28 that the people using the service are fully safe guarded. 4. OP29 19 Immediate and on-going. The volunteer who has been completing maintenance tasks in the home must cease to do so until all checks are clear. All staff must have up to date training in moving and handling and fire safety and infection control. Consideration should be given to providing training on dementia. This will ensure that the staff are trained to meet the needs of the people using the service. Previous requirement of 28/02/07 not met 07/02/08 5. OP30 18 01/04/08 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. Refer to Standard OP1 OP7 Good Practice Recommendations The home should have on display a copy of the registration document from the Commission for Social Care Inspection. 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 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. Any handwritten instructions on MAR charts must be written in ink, signed and dated. 3. OP7 4. OP9 Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 29 5. OP16 It is recommended that the Complaints Procedure be further developed to included timescales for dealing with any complaint. The manager should have a maintenance plan for the home, which includes details for replacing equipment and fittings. The Registered Manager must have a qualification in NVQ 4 (management and care) or equivalent. The manager should inform CSCI that one person is attending the home for day care. The home should continue to develop its quality assurance system. It is recommended that the Registered Manager attend the Manager’s training course run by the West Midlands Fire Service. The visitors’ book should be signed by all visitors, so that all people present in the Home can be safely evacuated in the event of a fire. 6. OP19 7. 8. 9. 10. OP31 OP31 OP33 OP38 11. OP38 Acorn Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Retirement Home DS0000020802.V345214.R01.S.doc Version 5.2 Page 31 - 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. 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