Inspection on 06/09/06 for Acorns

This inspection was carried out on 6th September 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.

Other inspections for this house

Acorns 29/11/07

Acorns 02/12/05

Acorns 14/06/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Acorns 29-31 Welholme Road Grimsby North East Lincs DN32 0DR Lead Inspector Stephen Robertshaw Unannounced Inspection 6th September 2006 and 13 November 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 Acorns DS0000063879.V311454.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. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorns Address 29-31 Welholme Road Grimsby North East Lincs DN32 0DR 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) 01472 340129 Pindy Enterprises Limited Position Vacant Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27) of places Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2005 Brief Description of the Service: The Acorns is a large Victorian house, which although retains many of its period features has been adapted to meet the needs of service users. The home is in the centre of a large residential area of Grimsby, overlooking Peoples Park, a well-known beauty spot. Local shops and other amenities are close to the home. The home is three-storeys, accessed by stairs and a passenger/chair lift. There are a number of sitting rooms and a large dining room. The house has parking to the front and rear and an adequate sized garden. The staff have their own working areas and there is also a large kitchen and outside laundry room. The home provides for the needs of service users from minimal needs to more complex needs. The home is supported by the local district nursing service and local GPs. Staff are encouraged to attend training courses and there appears to be good input from other health professionals. The current fees for the services provided at the home are between £329 and £335 per week. The only additional costs to service users are for hairdressing (female £4.50 and male £2), private chiropody services (£10), service users also have to pay for their own personal toiletries, incontinence pads, newspapers and transport. Previous inspection reports are made available to service users and visitors however this is kept in the upstairs office and is not advertised. As a result service users and visitors are likely to be unaware that they can access the report. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was a key inspection and was unannounced. The inspection was held on the 6th September 2006 and it was unannounced. The inspector was in the home for approximately seven and a half hours. There were twenty service users living at the home at the time of the site visit. The inspector was able to talk to twelve of the service users, two visitors to the home and to the manager and staff. The inspector and a regulation manager made a further visit to the home on the 13th November 2006 and looked at further information and met with the proprietors. The inspector had access to key documents such as care assessments, care plans, daily records and the home’s policies and procedures. The inspector also saw individual service users rooms and the home’s gardens. Four staff questionnaires were also returned to the inspector before the site visit took place. The manager had completed a pre-inspection questionnaire. This had been returned to the Commission prior to the site visit-taking place. The current owners of the home have been responsible for the home for a reasonably short time and are working steadily towards improving the standards of the home and the quality of the care provided to the service users. What the service does well: The staff are very friendly towards the service users and seem to understand what they need. They have good understanding of older people and this means that they can look after the service users and care for their individual needs. The experiences of the service users appeared to be positive in relation to how their care needs are met at the home. The service users are provided with a homely and friendly environment The staff work very well together and most of the staff have worked at the home for a long time. There is very little change in the staff group. This means that service users are able to get to know the people that are working with them and gives them time to build up good working relationships with them. Service users said to the inspector that when they are unwell the staff at the home always get them the health care that they need very quickly. One Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 6 service user stated how the home had helped his rehabilitation and was due to be discharged back in to the local community. The service users said that the atmosphere of the home was very relaxed and the environment was very homely. What has improved since the last inspection? 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. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 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 Acorns DS0000063879.V311454.R01.S.doc Version 5.2 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): 1,2,3,4 and 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. This means that the service user have their needs assessed before they are admitted to the home however the details of the homes assessments for privately funded service users are very basic. EVIDENCE: The homes statement of purpose and service user guide had been updated to include the details of the acting manager. This shows that prospective service users are provided with the correct information in relation to the home and the services provided there. However the home does also have a brochure, which is made available to prospective service users, and whilst not legally required, some of the information included in it is now out of date and slightly misleading. The Commission would recommend that this document is ceased to be used or is amended. A contract was available for all of the service users whose files that were seen by the inspector. These would benefit from development to include the identification of the room that is to be occupied by the service user. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 9 The inspector observed the case files for three of the service users that were living at the home. Two of the case files observed by the inspector were for service users funded through care management. Both of these had a local authority assessment and an assessment of need completed by the home after their admission. The third service user was privately funded and had been assessed solely on the basis of the homes pre-admission assessment. However the homes pre-admission assessment information was very basic and did not identify how the individual needs of service users affected their daily lives. The assessment was a series of tick boxes and did not include any detail of service users personal needs. Discussions between the inspector and the service users named in the assessments identified that despite this shortfall their needs were being met at the Acorns. Following the original site visit a further site visit was carried out by the inspector and a regulation manager and it was identified that new preadmission assessment material had been introduced to the home, however at the time of the visit this had not yet been utilised. Therefore the Commission was unable to comment on the effectiveness of the new system. However the assessment tool did appear to be much more comprehensive. Service user and visitors that were spoken to by the inspector stated that the home was able to meet their assessed needs. One service user said to the inspector that ‘ you couldn’t want for anything else’ at the home and that ‘it was very comfortable and the staff were very helpful’. Service users and visitors to the home confirmed to the inspector that they can visit the home at any reasonable time and that the staff always make them ‘feel welcome’. The home has appropriate policies and procedures for the admission of service users in emergency situations. However as stated earlier this would necessitate a more comprehensive assessment of need than is provided at present through the home. The home does not provide intermediate care for prospective service users. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. This means that the service users have individual care plans for all of their needs however they need to be developed to guarantee service users needs are met at all times in the home. EVIDENCE: The inspector observed all of the care plans for three of the service users living at the home. The care plans identified the majority of the needs identified in the service users’ original assessments and care management care plans. However the homes care plans are generic in nature and do not include all areas of need, or provide detail as to how service users’ individual needs must be met. For example a service user whose care management assessment identified behavioural, emotional, and obsessive behaviours were not included within the homes care plan. Another service user had specific restrictions placed on him and whilst the home believed that this was in his best interests to protect him it was not clearly recorded how the decision had been made, who had been consulted, and there was no reference in their care plan or risk assessments. The care plans had not been signed to signify the agreement to them by the service users or their representatives. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 11 The care files identified when service users had any contact with health or social care professionals that are based outside of the home. Some of these records did not include the outcome of the visits. As the care plans develop in the future and become more detailed the care staff will have to develop their skills in recording the outcomes of such visits and review the individual care plans as required. All of the staff that administer prescribed medication in the home had received accredited medication training. The inspector observed service users given their medication over a lunch period. All of the medication records were up to date, however two service users were left with their medication on the table and were not observed taking them, despite the medication record been signed as having been administered. The controlled medication in the home was limited to Temazepam and appropriate storage facilities were available. The records for the administration of the Temazepam were double signed to ensure that the safe administration and management of this medication took place. This is good practice. However if the home was to care for service users prescribed with schedule 2 medication then the recording system currently being used would be inappropriate. On the second visit to the home a controlled medication book had been purchased by the management. The filing cabinet that the medication records were held in was not lockable, this meant that confidential information was open to the general public. A new lock, or a new cabinet must be purchased if the records are to remain in this corridor and to maintain confidentiality. One service user living at the home was self-medicating. However there were no records kept of the medication that they had taken. The inspector spoke to the service user involved and the acting manager of the home and agreed that a medication record sheet would be supplied to the service user and they would complete it when they took their medication. This would ensure their health and safety especially in relation to hospital admissions where they would need to know any medications that had been taken. Service users spoken to by the inspector stated that they are always treated with dignity and respect by the staff. Care files identified the name that the service users preferred to be used for them. The service users confirmed that they receive all of their own mail unopened but added that if they needed support with any letters then the staff would help them. The home has three shared bedrooms and the service users spoken to by the inspector said that they were happy sharing their rooms. The manager said Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 12 there was no written agreement with service users who share a room. As no written confirmation was available it was difficult for the inspector to determine if service users would be able to occupy the room by themselves if the other service user vacated it, or if there would be an expectation for another service user to move in. It is therefore recommended that a written agreement is formalised for sharing rooms at the home, which ensures that service users are clear about what they are agreeing too. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 13 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): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. This means that the social activities made available to the service users are limited. Service users are generally able to make decisions about their daily lives and activities, however not all service users were happy with the variety of activities and restrictions on choice were not transparent. EVIDENCE: The service users’ daily routines are flexible this includes the times to rise from and retire to bed. Service users confirmed to the inspector that these times are to suit them and not the staff. There was also choice of where and when to eat their meals. The only religious preferences identified for the service users were Roman Catholic and Church of England. This was identified in the service users’ case files. A Catholic priest and a Church of England vicar regularly visit the home to meet the religious needs of the service users. The home had appropriate policies and procedures to support the service users with their sexuality and relationships however in one instance this had not been put in to practice and there was no evidence to support why their sexual needs were not being met and restrictions were in place. The manager has Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 14 stated that this decision to restrict had been made in the interests of the service user. There was no evidence that this judgement had been reached through a multidisciplinary meeting. Discussion with the identified social worker confirmed that she had not been involved in this decision, however the service user did not raise the restriction as a concern or issue. Transparent records of decision making of this nature must be available and supported by appropriate risk assessments. Care staff must not make decisions restricting choice in isolation. Those service users (5) asked confirmed to the inspector that they always see their family and friends in private and that they are supported and encouraged to develop links with the local community. The home employs an activity co-ordinator for three days a week. The service users were mixed in their opinions of the activities available to them. Three stated that ‘there is nothing to do in the home except sit around’ while others said ‘I like the different things that we do’. The activities appear to be limited in their content and could be developed further to include the interests of all of the service users so that they can individually choose to ‘join in’ when the activity available appeals to them. The activities that are currently available through the home include; bingo, entertainers, Karaoke, craft’s, dominoes and baking. Activities outside of the home include bingo, access to a day centre, church visits, shopping and visits to the local park. The acting manager and the activities co-ordinator control the residents’ fund. Fundraising events are held through the home to gain monies for the development of activities made available to the service users. The company also provides for activities in its operational budget. This ensures there is money available to provide for social activities though the home’s services. The inspector ate with several of the service users. The mealtime was observed to be unrushed and individual service users were offered appropriate support to eat their meals. One service user stated ‘the meals are always very good and you always get enough and can ask for more if you want to’. Special diets prepared within the home included low fat, low sugar and pureed meals. The presentation of the varying meals was good, including the pureed food. The kitchen was very clean and there were good stocks of food. The deep food fryer had one of the control dials missing (on/off switch) and this must be replaced to ensure safe working practices in the kitchen Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 15 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): 16,17 and 18 Quality in this outcome area is good. This judgement has been made form evidence gathered both during and before the visit to the service. This means that the service users are protected from potential abusive situations at the home. EVIDENCE: Since the last inspection there had been two complaints formally recorded at the home. These had both been recorded appropriately including the outcomes. The inspector suggested to the acting manager that the recording process for complaints in the home is changed to ensure the confidentiality of each individual complainant. There was also one referral to the local authority’s Protection Of Vulnerable Adults team. This was reported by the acting manager however the local authority decided to take no further action. All policies relating to protection of vulnerable adults had been reviewed. This included whistle blowing and the general abuse policy. Observation of service users individual care files identified if they had voted at national and local elections and if their preference was for postal votes. Training has been provided to some staff in relation to the protection of vulnerable adults. This training was provided through the local authority and a number of additional staff were booked on future events. The remaining staff Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 16 need to complete this training to ensure that all staff are fully up to date in this subject so that service users are protected from abuse. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. This means that the environment supports the needs of the service user but there are areas that still need to be improved to ensure their health and safety. EVIDENCE: Since the last inspection two of the bedrooms in the home have been decorated and a further five have been provided with new furniture. The two lounges and the dining area had also been decorated. New lighting had also been included in the lounge areas. The acting manager confirmed to the inspector that the curtains were also due to be replaced. A service user said to the inspector that the home was ‘more comfortable’ now that the redecoration had taken place. They also confirmed that they had been given the opportunity to personalise their own rooms to their tastes and preferences. A maintenance and renewal programme had been completed for the home. Although there was evidence that some redecoration had taken place. There Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 18 were still areas of the home in need of attention. This needs to be planned to ensure the service users are living in a well cared for environment. The toilet on the top floor had a broken the toilet seat. This has been a repetitive problem, however on the inspectors second site visit this had been repaired. One of the bathrooms downstairs had a block of soap left in it. This contradicts the control of infectious disease guidelines and this practice must stop to ensure the health and safety of the service users. Although some staff have received infection control training the home did not have policies and procedures in position to support communicable diseases in the home. On the second visit to the home these procedures were available to the staff and the inspector, however they had not been audited for some months and were not fully complied with. Although staff reported to the inspector that barrier equipment was not always available at the home the management were able to produce stock records and accepted that equipment was low only on one occasion and stocks were provided immediately from a local supplier. Two returned staff questionnaires showed that they believed that the home did not have enough moving and handling equipment to meet the needs of the service users. However observation in the home determined that there is adequate moving and handling equipment at the home and these are regularly maintained and serviced. The window restrictors had been purchased but they had still not been fitted to the windows and the Acting Manager was asked to make this a priority with the handyman. This is very important as some of the service users were suffering from symptoms of dementia and could be at risk from falling out of a window and also meant that unwanted individuals could enter the ground floor through open windows and possible abuse or steal from the service users. The garden area and outside of the home was tidy and was accessible to the service users. The home was very clean and was free of any offensive smells. The service users said that the majority of times they only got their own clothes back from the laundry. The home has a laundry with modern machines that are programmable to disinfection and sluicing standards. These also have automatic feeds for the cleaning materials and this minimises the risk of staff coming in to contact with any caustic materials. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 19 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): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. This means that the staff training does not ensure that they can meet the needs of the service users. EVIDENCE: Service users spoke positively about the way in which the care staff looked after them and treated them. The inspector observed three of the care staff’s personnel and training files. These did not include all of the information that is required by schedules 2 and 4. One file pertaining to a new recruitment only included one reference and the homes reference forms do not recognise the person who has supplied the reference. Contracts were also missing from some files and staff said to the inspector that they had not received contracts from the new company that owned the home. Not withstanding the positive comments received about the staff, the quality of the staff induction was basic and not to the specified standards, this document was inherited from the previous ownership and had not been updated. This was further compromised by the way in which staff training had been coordinated, this had not been managed in a proactive way. On the second visit to the site the management of the home had obtained a new induction and foundation-training package that will be introduced to all Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 20 staff working at the home. The acting manager of the home had been on a training course to provide this training, however it was yet to be implemented. Three staff stated that they are not provided with the required paid training to ensure that they can meet the needs of the service users. Management records provided evidence that some staff are provided with over and above the recommended three days training. However this was not always the case and in one instance it was observed that the member of staff had not attended training despite numerous training reservations made by the management. Non-attendance at the courses incurs a fee to the management of the home. The system for the recording of staff training in the home did not identify who had completed training and when refresher training was required. On the second visit to the site a new training a new matrix had been developed but had not been tested. The acting manager needs to identify the staff group training needs to ensure that the home is maintaining the staff’s requirements for mandatory and service specific training. There are twenty care staff employed at the home. Three staff have completed NVQ 3 in care and a further three staff are working towards NVQ 2. The acting manager has secured additional funding for NVQ training and a further five members of staff will be enrolled on NVQ 2. The staff rotas indicated that the home meets the requirements for the numbers of staff available on duty. The proprietors prefer to limit the use of agency workers and prefer to use their own staff to cover vacant shifts as they feel this is more beneficial to service users. This means that the acting manager has to rely on the good will of the existing staff to cover any shortfalls. Staff stated that they cover these shifts to make sure that the service users are well looked after but they were very tired. The home has a structured staffing system to ensure a responsible person is always available. Staff questionnaires said that there was sufficient staff at the home during the week, however at weekends this was difficult as they also had to complete domestic and laundry duties. At the previous inspection ‘it was recommended to the acting manager that this be reviewed so those on the care staff rota are not taken away from attending to the needs of service users at weekends’. Day staff are expected to arrive at work fifteen minutes before their shift starts for a staff handover. Two staff were reluctant to do so. Two stated that since the new proprietors took over the service their pay has been reduced. However previous contracts and present pay details evidenced that the staff pay had actually been increased. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 21 The staff team are very supportive of one another one returned questionnaire stated that ‘the staff have been very helpful showing’ me ‘what to do’. Acorns DS0000063879.V311454.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made through evidence gathered both during and before the visit to the service. This means that there has been no consistent management in position for sometime and whist improvements are taking place there is still a reasonable amount to do. EVIDENCE: The acting manager of the home had experience in the care field and was enrolled on the Registered Manager’s Award. She had been in position for approximately nine months. The acting manager stated that she did not have a contract from the providers specific to her role within the home. However there was a manager’s job description available. The Commission had not received an application from her to be accepted as the registered manager. The acting manager was working towards the Registered Managers Award and was currently on an approved medication course. She had also completed a Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 23 Training for Trainers course in relation to moving and handling so she can make sure that the staff training in this area is up to date and the best interests of the service users are being maintained. Most of the staff stated that the acting manager was supportive of them and their needs however one responded that ‘management did not listen to the staff’ it was unclear if this reference was towards the acting manager or the external managers of the home. On the second visit to the home the owners were able to demonstrate that they had provided a cheque to the acting manager and were prompting her to make an application to the Commission. At the time of the second visit by the inspector a new acting manager was in position. The owners of the home must ensure that an application from the manager is received by the Commission in the near future. Two staff that were interviewed, one staff questionnaire and four service users spoken to by the inspector all stated that they were aware of the new owners of the home but that they had little contact with them and when they visited they believed that it was purely for business reasons. The previous owners were resident at the home and as the new owners are not resident this may look to others that they are not meeting their responsibilities. However their personal records indicate that they visit the home at various times unannounced to the staff and meet with staff and service users. However the quality of the records for these visits were inconsistent. The home’s quality assurance and monitoring systems are still in the early stages of development this will be looked at more closely at the next key inspection. The first questionnaires have been distributed and the first results have been listed. An action plan needs to be developed and the results should be made public. Some mandatory and service specific training has taken place since the last inspection and the acting manager could show the inspector training which is to take place in the next couple of months. It was difficult to identify the training received by individual members of staff, or when the training needed to be refreshed. The homes new training matrix should improve this area. Records of all finances were up to date and a business and financial plan detailing the projection of costs was available up to 2009. Appropriate insurance was identified to be in position for the home. Service user accounts that were sampled by the inspector were appropriately accounted for and that also included the records for the home’s ‘residents fund’. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 24 Staff supervision records showed that the home is working towards the minimum recommendations for recorded supervision for all of the staff but hasn’t quite achieved this yet. The records held in the home were in the main all up to date. As previously identified not always held securely or confidentially and most would benefit from including greater detail. This included assessments, care plans and daily diary records. The majority of the homes health and safety requirement were met and service and maintenance records were up to date. The acting manager reported that several of the required policies and procedures for the home were not in position this included policies and procedures for: communicable diseases, COSHH, Fire safety, first aid, Health and safety at work and hygiene and food safety. On the second visit to the site these policies and procedures were made available to the inspector. The audits of the home’s policies and procedures had ceased to be audited from May 2006. The proprietor confirmed that these had not been strictly adhered to by the home’s staff including staff not signing to state that they had read and understood some of these policies for example health and safety in the kitchen area. Acorns DS0000063879.V311454.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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 3 3 2 1 3 Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 (1a and b) Requirement The registered person must ensure that the homes preadmission assessments are developed to include clearer detail of how service users needs affect them and the support that they require throughout their daily lives. The registered person must ensure that individual service users individual care plans identify how their individual needs must be met. The registered person must ensure that all prescribed medication is appropriately administered and monitored at the home. The registered person must make sure that all service users that are self-medicating have appropriate records maintained of the medication that they have received in case of medical emergencies. The registered person must make sure that all restrictions identified as part of a multidisciplinary review are recorded DS0000063879.V311454.R01.S.doc Timescale for action 06/11/06 2. OP7 15 (1,2a,b, c and d) 13 (2) 06/12/06 3. OP9 07/09/06 4. OP9 13 (2) 11/09/06 5. OP14 12 (3, 4a) 01/12/06 Acorns Version 5.2 Page 27 6. OP29 19 (1a,b, and c, 5a,b, c and d) 7. OP30 18(1 c i and ii) 8. OP30 18.(1.c.i and ii.) 9. OP31 8 (1 and 2) 10. OP31 8 (1 and 2) 11. OP37 17 (1b) 12. Acorns 17 and 24 within the care plan and are supported through clear risk assessments. The registered person must ensure that appropriate recruitment procedures are carried out by the home and staff personnel files include all of the information required by schedules 2 and 4. This includes an improvement required to the homes reference forms to identify who supplied the reference. The registered person must ensure that all staff working at the home receive a minimum of three days paid training per year to ensure that they understand and can meet the needs of the service users. The registered person must ensure that an annual training programme is in place and all staff have received up dated training in all mandatory and service specific training. The registered person must ensure that the manager of the home is competent and has completed a fit person interview with the Commission to be accepted as the Registered Manager. The registered person must provide the manager of the home with a contract detailing the manager’s roles and responsibilities. The registered person must ensure that all confidential materials are appropriately stored in the home. The content and detail of some of the records also needs to be improved this includes the service users assessments and care plans. The registered person must audit DS0000063879.V311454.R01.S.doc 30/09/06 30/09/06 30/09/06 30/10/06 30/09/06 30/09/06 30/10/06 Page 28 Version 5.2 OP19 OP37 (1 a and b, and 3) all policies and procedures in the home and make sure that they are complied with. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP1 OP2 OP7 OP7 OP10 Good Practice Recommendations The registered person should ensure that an up to date brochure is available to the service users or is ceased to be used. The registered person must ensure that the service users are all provided with an appropriate contracts that include all of the information required by NMS 2.2 The registered person should make sure that the service users or their representatives sign their care plans to demonstrate that they agree with them. The registered person should make sure that all of the window locks that have been purchased are appropriately fitted to ensure the health and safety of the service users. The registered person should make sure that all service users that share a bedroom at the home have written consent agreeing to this. The registered person should make sure that the activity programme for the home is developed further to include the interests of all of the service users living at the home. The registered person should continue with the homes programme of protection of vulnerable adults training to make sure that all staff are aware of abuse issues and how to appropriately report suspected abuse. The registered person must ensure that all toilets and bathrooms meet infection control standards and appropriate infection policies and procedures must be developed for the home. The registered person needs to be aware of the homes responsibilities towards the 50 target for NVQ level 2 trained staff working in the home. The registered person should show consistency in the recording of the recording information in the home. The registered person should continue with the development of the homes quality assurance and DS0000063879.V311454.R01.S.doc Version 5.2 Page 29 OP12 OP18 8. OP21 OP19 9. 10 11. OP28 OP32 OP33 Acorns monitoring programme to develop an effective system. 12. OP36 The registered person should make sure that the staff supervision continues to improve to meet the recommended minimum of six formal supervision periods a year. Acorns DS0000063879.V311454.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Acorns DS0000063879.V311454.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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