Inspection on 23/01/07 for Acorns Care Centre

This inspection was carried out on 23rd January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Acorns Care Centre 12/12/05

Acorns Care Centre 21/07/05

Acorns Care Centre 05/11/04

Acorns Care Centre 17/06/04

Similar services:

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Chirnside House

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

CARE HOMES FOR OLDER PEOPLE Acorns Care Centre Parkside Hindley Wigan Greater Manchester WN2 3LJ Lead Inspector Sue Donovan Unannounced Inspection 23rd January 2007 08:15 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 Care Centre DS0000030090.V288651.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 Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorns Care Centre Address Parkside Hindley Wigan Greater Manchester WN2 3LJ 01942 259024 F/P 01942 259024 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) Mr Kevin Hall Anne Susan Gardner Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Terminally ill over 65 years of age (2) of places Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users, to include: Up to 39 service users in the category of OP (Older People); Up to 2 service users in the category of TI (E) (Terminal Illness over 65 years of age) The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. That at all times a suitably qualified registered nurse is working in the care home. 12th December 2005 2. 3. Date of last inspection Brief Description of the Service: The Acorns Care Centre is located on the outskirts of Hindley town centre, close to shops, a park, and other amenities. The main bus route runs close by. The Acorns is purpose-built, and accommodation for service users is provided on three floors. Accommodation is provided for a total of 39 service users, both male and female, who are over the age of 65. The Acorns provides nursing and personal care. Within the total of 39, two service users may be accommodated who are over the age of 65 and who are terminally ill. All accommodation is offered on a single-occupancy basis. All bedrooms have en suite facilities. Parking for visitors is limited. The current range of charges is £391.36 - £475 nursing banding. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told the inspection was to take place. The site visit took place over an eight hour period from 8:15am to 4:15 pm. The report was written after looking at the information sent to the Commission for Social Care Inspection (CSCI) including comment cards, one from a relative and one from a resident, and after talking to the residents, their relatives, the manager and staff. During the inspection, care and medicine records were looked at to make sure resident’s needs were being met. The inspector looked around the building to check if it was clean and well decorated. The food that was served for lunch was looked at and the records checked to see how the home and its equipment were kept safe. No complaints had been received by the CSCI since the last inspection. Residents said, “they are very good staff, not one I could complain about,” and “they are all very nice.” What the service does well: Residents are assessed before they move into the home to make sure the Acorns Care Centre can provide the care they want and need. The home has good facilities and has three lounges for residents to spend time in. The manager and staff know residents well and spend time making sure they are cared for the way they need to be. A relative said, “they are all very good staff.” Good meals are provided. A resident said, “they will make anything, always an alternative.” The home is good at contacting doctors and district nurses when necessary. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Acorns Care Centre DS0000030090.V288651.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 Care Centre DS0000030090.V288651.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Up-to-date information is given to residents and their families to enable them to make a decision as to the suitability of the home. Prospective residents have their needs assessed prior to admission to assure these will be met. EVIDENCE: A statement of purpose and service user guide was available to residents and their representative to help them to decide if the home and the services it provided could meet their needs. The statements of purpose (SOP) and service user guide (SOG) were displayed in the reception area. The detailed information covered all the required areas and included a description of the services and facilities, how to complain and privacy and dignity. A summary of the information is placed in new residents rooms ‘welcome to the Acorns Care Centre’. This lists the staff and their roles, gives the times of meals and introduces their key worker to them. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 9 The reception area of the home held a number of other documents for relative’s information and interest for example a sample of menus and other agencies contact details. The area provided coffee and a board showed what staff were on duty each shift. Three residents files were inspected and each contained evidence of the homes assessment for both funded and self-funded residents. Two files also held Social Services or hospital assessments. This information had been used when writing the residents care plans (the information that staff need to be able to meet residents needs.) A discussion took place regarding the assessment process that was undertaken when someone wanted to come and live at the home. The person is visited at home or in hospital and they are invited to spend time there if they are well enough. The admission information seen on resident’s files was comprehensive dated and signed. More information would be beneficial on resident’s likes/dislikes, interests and hobbies, memorable life events and social contacts. The manager said that she had recently given a member of staff the role of ‘well being’ nurse. Her job would be to spend time with residents and their families and document any relevant information. This information was not yet seen on the files inspected but when compiled will help the home provide the care residents want and need. A resident said that he had tried another home before coming to live at the Acorns and was happy with were he now lived saying “I get the care I need ” “it’s okay here.” Acorns Care Centre DS0000030090.V288651.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system in place provides staff with the information they need to meet resident’s health and personal care needs. The medication system was safe but could be administered so resident’s meals are not disrupted. EVIDENCE: Three care plans of residents were looked at. The plans contained information about how to care for the residents. Completed care plans showed health and personal care needs and recorded the actions to be taken to meet these needs. There was evidence on files that staff were reviewing care plans on a regular basis (at least monthly). A senior carer or a nurse completes the care plans. Recently the manager has introduced a carer knowledge log to show that care assistants have read and are aware of the content of care plans; the staff sign and date the sheet when this has been done. Evidence of this was seen and Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 11 one care assistant said, “I didn’t realise you had to stand on X’s left, I know now I’ve read the care plan.” Staff meeting minutes (January 2007) showed that it had been discussed how important it was to read the care plans. One care plan held a residents preferred activity sheet. This showed the resident enjoyed reading, listening to the radio, attending the church service and watching television. The resident confirmed that she enjoyed all of these activities and staff where aware of what she needed and enjoyed. On another care plan the section on working and playing only said, “seems a sociable lady.” It was discussed with the manger that more information was needed in these sections. Care plans recorded the involvement of doctors, district nurses and other health care professionals including visits by the chiropodist and optician. Residents were weighed monthly and their weight monitored. A nurse said that they had asked for some hoist scales and these had been provided within a week. Nutritional assessments and records of food and fluid intake were also completed if any change was noticed. Drinks were offered to residents on a regular basis throughout the day the inspection took place. Daily records on resident’s files were completed twice a day everyday and held good information. Residents spoken with considered they received “good care” which was described by one resident as “I get the care I need.” A relative said, “its very good care” “they have done everything to help her from falling.” A comment card returned by a relative to the CSCI indicated that they had been consulted about their relatives care and that they were satisfied with the overall care provided. Risk assessments were in place and up-to-date and covered areas such as falls moving and handling and wheelchairs. All risk assessments and care plans had been reviewed on a monthly basis and altered if necessary. The activity programme at the home (see life and social activities section) includes activities to keep residents active and includes armchair aerobics. Staff said that many residents used the garden area when the weather permitted. Medication policies and procedures were in place. Only the nurse on duty administers the medication. The medicines room was clean and tidy, kept locked and medicines were securely stored. The drugs refrigerator temperature was satisfactory but the temperature had not been recorded for two days. This should be recorded on a daily basis. Most medication was supplied in a monitored dosage system (MDS) with preprinted medication administration records (MAR). Medication appeared to be Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 12 given and signed correctly. Resident’s photographs help ensure medication is administered correctly. The home has a controlled drugs register and entries corresponded to the amounts held at the home. Medication was administered during the lunchtime meal. It should be considered if medication could be administered so that residents do not have their meals disturbed. On the day of the inspection site visit observations showed that personal care and hygiene needs were met in a discreet and sensitive way. Staff were observed knocking on doors and explaining to residents what they were doing when transferring them form the armchair to their wheelchair. Many residents at the Acorns are nursed in bed but staff called into their rooms on a regular basis. Care staff inform the nurse on duty or senior carer of any change in their condition. All rooms have a call system fitted and one resident said, “I like to be independent but I have a buzzer if I want them; they always come.” Acorns Care Centre DS0000030090.V288651.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A social activity programme is normally provided on both an individual and group basis for the enjoyment of residents however community access is limited. Visiting arrangements at the home are good, ensuring links between residents and their families and friends are maintained. Food was well balanced and nutritious, the options for residents needing soft diets could be improved. EVIDENCE: An activities co-ordinator is employed at the home but she is currently absent from work. She normally works Monday and Tuesday afternoons, Wednesday mornings and all day Fridays. The programme of activities that is normally available was displayed in the home and included bingo, armchair aerobics, pamper sessions and discussion groups. A hairdresser visits the home weekly and will provide a service for the residents in their own room or in the homes hairdressing salon. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 14 Some residents prefer to spend time in their own rooms and others are cared for and nursed in their rooms. Two residents spoken with said, “ I don’t go in the lounge. I like reading, watching the television and listening to my radio,” and “I’m comfortable in my room. I like having my hair done.” Entertainers come into the home occasionally and the upper floor lounge is used for these occasions and for birthday parties/family events. One resident goes out to the pub each Friday with the activity co-ordinator and he said that he was missing this but had declined to go when staff had offered to take him. During the afternoon of the inspection relaxing music was played in the lounge and staff spent time with residents chatting. Staff spoken with said that more community activities would benefit some residents but they do manage to go out in summer for walks or shopping. The home had an open visiting policy. A relative of a resident said “I can come when I want.” Residents can see their visitors in the lounges or in their rooms. A visitors book showed the times visitors had called. Posters and leaflets are available in the reception area informing families and friends of local advocacy services that are available. Communion is held for residents of the Roman Catholic faith once week and the Church of England minister will call on request. The choices residents made each day were varied. Residents were generally free to choose what time they go to bed, what clothes to wear, what to eat and how to spend their day (when activities are available). Menus inspected were seen to provide a nutritious and varied diet over a twoweek period. The cook said that there were always two choices at both the lunch and evening meal and there were five fruit and vegetables incorporated into the menu each day. Residents confirmed this saying; “there is always plenty of choice.” Fresh fruit was seen in the dining room and was available at all mealtimes. A resident visited had fresh fruit in her room. Lunch was observed. The dining room was clean and bright and staff served the residents. Some resident’s food was taken from the kitchen to their rooms. The lunch consisted of lamb grills, potatoes and vegetables or soup and sandwiches followed by ginger sponge and custard or fruit and ice cream or yogurts. A sugar free sponge was available for residents on special diets. Hot drinks were provided and served from large vacuum flasks. Staff had teabags and coffee so they could make the drink to the residents liking, at the time during the meal that they wanted it. Residents needing a soft or pureed diet were given the same foods as other residents but liquidised. Speech therapist advice may provide information for the cooks’ re- the consistency of food needed for individuals and alternative ways of presenting the food. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 15 Residents were in general complimentary about the meals saying, “they will do anything for you,” “meals are good,” but one resident said “ Okay, not enough variety. I’d like more stews and hotpots.” A room service option is available for residents who can choose to go to the dining room or eat in their rooms or order a snack. A resident said that she goes down for breakfast and lunch but chooses to eat her tea in her room. “they bring my tea up for me.” Acorns Care Centre DS0000030090.V288651.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives were confident that their complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: The home had a complaints procedure that was included in the service user guide/handbook. A copy of this was in the reception area and displayed on the wall. A user-friendly complaints poster using photographs and symbols would enable relatives to see the poster easily amongst the other information displayed in the reception. Residents and relatives spoken with said they knew to see the manager if they wished to raise a matter of concern. A complaints log was available and showed that both minor concerns and more serious complaints were logged, fully investigated, action taken and the outcomes recorded. The CSCI had not received any complaints about the home since the last inspection. A compliments file was on display in reception. This contained many messages of thanks from families for the care of their relatives. The last was dated 17/1/2007. Compliments included “extremely satisfied with the comfortable Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 17 surroundings and high standards of care at The Acorns,” and “ thank you for the support you and your staff gave.” A procedure for responding to allegations of abuse was available as was the Wigan interagency safeguarding adults procedure. Staff spoken with understood the importance of reporting bad practice and said that they would report it immediately to “the manager” “ the person in charge on the shift.” Training records showed that staff had received training in the protection of vulnerable adults (POVA) as part of their induction and in in–house training sessions. The manager had recently completed part one –safeguarding adults for managers arranged by the local authority. Three recruitment records examined showed that two staff had appropriate checks and records in place but one staff had not had a criminal record bureau (CRB) check prior to starting work at the home (see staffing section of report.) Acorns Care Centre DS0000030090.V288651.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, clean, pleasant, hygienic and well maintained building was provided for residents. EVIDENCE: The Acorn care centre is a purpose built home close to the centre of Hindley. The home has a safe garden area and car parking for visitors and staff. The home was safe, well maintained and clean. It is maintained by Mr Hall the owner who calls in on most days. The home is on three floors and is serviced by a passenger lift. The ground floor houses the dining room, laundry, five bedrooms and a small lounge that is currently used by residents who smoke. The second and third floors have seventeen bedrooms on each, a sluice, a large lounge and offices. All floors Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 19 have toilets, showers/bathrooms. Corridors had handrails and grab rails were provided beside toilets. The shower rooms needed additional tiling. The paint was peeling off the walls and looked unsightly. Bathrooms were currently being used to store equipment. This should be moved so that it does not pose a risk to residents. The home was well decorated and the manager said that part of the dining area and some bedrooms had been decorated in 2006. Although the standard of the decoration and the furniture and fittings were good a planned programme of decoration would ensure that all areas of the home continue to be maintained to an acceptable standard. Signage round the home was clear and toilets were close to communal areas. All three floors were decorated in different colours so residents know which floor they are on when using the lift. The home was generally clean, hygienic and free from unpleasant odours on the day of inspection. Policies and procedures were in place with regard to infection control. Staff were provided with disposable gloves and other personal protective equipment. Liquid soap and paper towels were near hand washing facilities. Staff were observed to be maintaining good hygiene practices. Environmental health and the local fire service had visited February 2006 and October 2005. Remedial action required had been implemented. The laundry area was sited away from food preparation areas and was seen to be clean and orderly. Sufficient and suitable equipment was provided and the laundry was attended to efficiently. A laundry assistant is employed at the home There were no complaints about the standard of care provided with resident’s personal clothing. One resident said, “ all my washings lovely.” Acorns Care Centre DS0000030090.V288651.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were provided to meet the needs of residents. Recruitment and selection policies need to be checked to ensure residents are protected. The majority of staff were trained and competent to do their jobs but needed paid time to attend training. EVIDENCE: Inspection of rotas showed that the home currently had on duty seven staff in the morning (six carers and one nurse), six staff in the afternoon and evening (five carers and one nurse) and four staff on night duty (three carers and one nurse). Staff felt there were enough staff to meet the needs of the residents presently living at the home. However some staff said that they were tired and had been covering on a regular basis for staff sickness. This needs to be monitored to ensure staff have sufficient rest time. Observation showed that residents had a good trusting relationship with staff. Residents said, “they are all nice, “and “very good staff, not one I could complain about.” Over 50 of care staff had an NVQ 2 in care qualification. Two staff spoken with said that they were hoping to enrol and start their NVQ this year. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 21 It was evident from talking to staff that they enjoyed working at the home saying, “ great staff we work as a team,” “I like working here,” and “ I love working with the residents.” Inspection of three staff files showed that on two files CRB checks had been carried out. On the other file no CRB disclosure was found. The member of staff had brought with her the CRB disclosure check from her previous employment. This is not acceptable. CRB disclosures are not portable. The manager said this would be applied for immediately. All files showed that other recruitment procedures were followed. References and evidence of fitness were in place as necessary. PIN numbers for nurses were seen on personal details sheets and were all current. Evidence was seen to show induction was provided when staff started to work at The Acorns. Staff said they had got to know residents, shadowed other workers until they felt confident enough to work alone and undertaken training. The manager said that all care staff undertake a twelve week induction and complete a series of eight work books which ensures they have knowledge in for example health and safety, food hygiene, individuality and communication. A training matrix, training plan (for the next six months) and individual training records were all in place. The records showed training had taken place over the last twelve months and staff confirmed this. Training included, principles of care individuality and human rights customer service the role of the care assistant in the care of a resident with diabetes nutrition in the elderly understanding strokes Staff currently attend some of the courses in their own time. All staff should receive a minimum of three paid days training per year (including in-house training.) A relative said, “ they are very good staff” and “very good care here.” Acorns Care Centre DS0000030090.V288651.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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective leader and quality assurance systems are in place to ensure residents and relatives can voice their opinion. The home ensures that resident’s monies are safeguarded and has a good system for ensuring the health and safety of residents. EVIDENCE: The registered manager is a registered nurse who has many years experience. During the last twelve months she has gained a diploma in management and has also attended health and safety, safeguarding adults and infection control courses to update her knowledge. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 23 All the requirements made at the last inspection had been met for example the care plans where up-to-date and reviewed on a regular basis. The home had a quality audit policy this included annual surveys to gather the views of residents and relatives. The last family survey was in June 2006 and a catering survey took place with residents in the March. Other stakeholders for example social workers and doctors had not been surveyed; this would be beneficial to gather their views on the service provided. Other systems of gathering feedback included six monthly resident and staff meetings. The last residents’ meeting was held in September and was attended by sixteen residents. At the meeting activities, laundry, catering and the quality of the care were discussed. The manager also had meetings with the owner at which quality assurance and staffing were discussed. The system for safeguarding resident’s money was good. Their relatives generally undertake the management of resident’s finances. Only personal allowances are held for any purchases or to pay for hairdressing. Money was found to correspond to the log for the resident that was checked. The manager supervises staff on a day-to-day basis and there was evidence that staff receive supervision in one to one meetings but only once or twice a year. In order for all staff to receive a minimum of six supervisions a year the responsibility could be delegated to other senior staff working at the home. The home had a health and safety policy. Regular weekly checking and testing of the fire detection system took place. A fire risk assessment was seen and was last reviewed in December 06. It was noted that although the water temperatures had been tested and this recorded monthly through most of the year these had not been recorded since August 2006. Water temperatures must be tested and these documented at least monthly for the safety of residents. Portable electrical appliances had been tested on 21/09/06. The accident records were examined and found to be appropriately maintained. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 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 2 X 3 Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19(4)(bi) Requirement For the safety of residents the manager must check that all staff working at the home have a Criminal Records Bureau enhanced disclosure for their current post. All staff should receive a minimum of three paid days training per year (including inhouse training) to ensure they have the necessary skills for their role. Timescale for action 28/02/07 2. OP30 18 (c) (i)(ii) 30/04/07 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 OP3 OP12 Good Practice Recommendations The manager should obtain more information on resident’s lifes before moving to The Acorns Care Centre and use this information when developing their plan of care. For the well being of residents the manager/owner should consider how activities for residents can be provided in the absence of the activities co-ordinator. DS0000030090.V288651.R01.S.doc Version 5.2 Page 26 Acorns Care Centre 3. 4. 5. 6. 7. 8. 9. OP15 OP16 OP19 OP19 OP19 OP33 OP38 Advice/training should be sourced for staff regarding the foods needed by residents who require soft/liquidised foods with regard to consistency and presentation. A clear easy to understand complaints poster should be displayed in the entrance to the home giving residents and relatives the information they need to air any concerns. A planned programme of decoration should be developed to ensure all areas are maintained to a good standard. Alternative storage should be found for equipment currently being stored in the bathrooms so residents are not put at risk. The shower rooms should be tiled were the paint work is peeling off and is unsightly to improve the environment for residents. A survey of other stakeholders (i.e. care managers, social workers, doctors, and other health professionals) should be carried out and the results used to improve the service. The water temperatures must be tested at least once a month to ensure there is no risk to residents and staff. Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Acorns Care Centre DS0000030090.V288651.R01.S.doc Version 5.2 Page 28 - 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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