Inspection on 11/07/06 for Acre Green Nursing Home

This inspection was carried out on 11th July 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

Acre Green Nursing Home 05/07/07

Acre Green Nursing Home 30/11/05

Acre Green Nursing Home 12/07/05

Acre Green Nursing Home 13/01/05

Acre Green Nursing Home 03/08/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Acre Green Nursing Home Acre Close Middleton Leeds Yorkshire LS10 4HT Lead Inspector Chris Levi Key Unannounced Inspection 08:30 11th &12th July 2006 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 Acre Green Nursing Home DS0000001317.V297846.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. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acre Green Nursing Home Address Acre Close Middleton Leeds Yorkshire LS10 4HT 0113 2712307 0113 2714965 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) Southern Cross Care Management Limited Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2), Terminally ill over of places 65 years of age (2) Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Acre Green is a 50 bedded care home with nursing beds. The two storey home is built around a central courtyard and provides residential care in the 20 beds on the ground floor and nursing care and higher dependency care in the 30 beds on the first floor. All rooms have en suite facilities. The two floors are staffed and operate as separate units with a nurse on duty 24hrs on the first floor. The kitchen and laundry for both units are on the ground floor with a small serving kitchen on the first floor. Each floor has two lounges and a dining area. A passenger lift provides access between the floors. The central courtyard provides a safe sitting area and land to the side of the building is landscaped to offer additional outdoor space for the use of residents and their families. There is a generous parking area in front of the building.The home is situated in the centre of a residential area in Middleton on the outskirts of Leeds on the site of a former local authority residential home. Local community facilities include a health centre, library, bowling green, day centre, club, shop and a school. A large retail shopping mall is approximately five minutes drive from the home. The current weekly fees charged by the providers is £390- £465. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection in July 2006. The contents of Inspection reports are discussed at staff, relative and residents meetings. A copy of the report was displayed in the entrance hall. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced inspection by one inspector took place over two days, starting at 8.30am until 4.45pm on the first day and 8.15am to 1pm on the second day. The person in charge of the home was the manager, Ms S Hague. Feedback on the findings of the inspection was given to the Manager, the Care co-ordinator and the Operations Manager at the end of the visit. On the days of the inspection there were thirty-nine residents living at Acre Green. A number of these residents on the first floor had high dependency needs. The inspector would like to thank everyone who took the time to talk to me and express their views. This report reflects the preference of people living at Acre Green to be collectively referred to as residents, rather than service users. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents, complaints and compliments from service users and relatives. This information was used to plan the inspection visit. During the visit to Acre Green the inspector case tracked a number of residents. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method the inspectors assessed all twenty-two key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspector spoke with identified residents and relevant members of the staff team who provide support to the residents. Documentation relating to these residents was looked at. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 6 Where possible contact was made with relatives and other external professionals to obtain their opinions about the quality of services provided at the home. Two residents completed a CSCI survey and gave their individual views about living at Acre Green. Surveys and comment cards for residents and relatives were left at the home. These cards provide people with an opportunity to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. A number of direct quotes from residents, staff and visitors were also included in the report. What the service does well: What has improved since the last inspection? Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 7 The new manager and her deputy have introduced a number of changes to the way staff work whilst on a shift to give a more focused service to residents. When this is fully implemented standards of care for residents should improve further. Care plan documentation has improved, but there is a need to monitor and maintain this improvement for the benefit of continuity of care for residents. Staffing levels have increased but residents do not appear to have benefited due to lack of leadership by nurses who manage the first floor. A recurring comment from visitors and external professional was “ they always seem short of staff. There is a never a staff member available.” What they could do better: The 5 yearly electrical installation safety check must be carried out. The smoking room lounge door on the first floor must not be wedged open, as this may increase the risk to residents should a fire occur. The number of care staff with NVQ level two needs to increase to achieve the target of 50 of care staff holding an NVQ level2 qualification. Communication between members of staff must be improved. The current lack of effective communication between members of staff is having a negative effect on the care of residents. On the first floor the nurses are not managing the shift effectively. This results in some care staff doing what they want, rather than what may be in the residents’ best interest. Nurses who administer medication to residents must do so in accordance with the Nursing and Midwifery Council administration of medication guidelines. The number of staff absences has an impact on the levels of care given to residents. The management team are currently dealing with this issue. Some members of staff would benefit from retraining in the core values of dignity, respect and privacy to improve levels of service to residents. The staff training programme must include adult protection, as staff current understanding and awareness needs to improve. Residents with low weight must have an effective care plan that identifies what action is required of staff. This should include the recording on daily food charts, weekly weights and referral to dietician and GP if necessary. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 8 The recording of social activities should be reviewed. The homes activities coordinator should consider writing entries in a social activities care plan that is part of the overall documentation about the individual resident. The home should demonstrate that one to one activities are available for those residents unable or unwilling to join in group activities. Risk assessments should be reviewed on a regular basis to ensure they are still relevant. The manager must ensure that the home does not admit residents whose dementia needs are the primary reason for care. The heated trolley that transports food to the first floor dining room should have a hazard sticker on it, to minimise the risk of injury to staff and residents. 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. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 9 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 Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 10 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 and 4. Quality in this outcome group outcome is good. This judgement has been made because evidence demonstrated that the manager provides good quality information to prospective residents and their families about the services provided at Acre Green. Appropriate assessments of residents needs are considered before moving to the home. These are thorough and well documented. However, the manager must ensure that the home does not admit residents with primary needs of dementia care. There was evidence that a resident had been admitted inappropriately and moved as an emergency to a home providing dementia care. The majority of residents or their representative have copies of the terms and conditions identifying their rights and responsibilities whilst living at Acre Green. EVIDENCE: The Statement of Purpose provided by Southern Cross, the organisation that owns Acre Green has been updated. The Service User Guide produced by the Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 11 Manager of the home is adequate in providing potential residents with information about the services available. At a later date it could be revised to become a more personal document, to include quotes from people living at the home, photos and more detail about daily life as a resident of Acre Green. A relative said she had come to visit the home before agreement was reached about her relative moving in. Only seven of the residents have not received a written contract about their rights and responsibilities when living at Acre Green. The home administrator is aware that these need to be issued. The contracts for self-funding residents are updated annually, when the weekly fees are increased. Those funded by a local authority do not receive an amended contract. The home has a comprehensive pre admission assessment form. This enables senior staff to decide if the needs of prospective residents can be met at Acre Green. It provides sufficient information to enable staff to formulate a basic plan of care at the time of admission for the resident. The manager should ensure that the home does not admit residents with dementia, as the home is not registered to provide care for this service user group. It was noted during the inspection that a number of residents with dementia had been admitted to the home. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 12 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 group outcome is adequate. This judgement has been made because evidence was seen that: Care plans were adequate to meet the personal and health needs of the residents. There was evidence of ongoing work to improve the information contained within them. The home has a comprehensive procedure for the administration of medication to residents. However, the nurse administering medication on the first floor did not follow the procedures. This could put residents health at risk. The dignity and respect shown by staff to resident was not consistently satisfactory. Examples of good and poor practice were observed during the inspection. EVIDENCE: Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 13 Three residents were case tracked during the inspection. This involved looking at every aspect of their life at Acre Green. Their care plans were adequate in the quality of information about their health and personal care needs. This information tells staff how to provide care and support to individual residents. There was evidence that the resident or a representative had agreed to the plans of care and that they were reviewed on regular basis. Risk assessments were in place when a risk to a resident had been identified. These assessments should be reviewed, as part of the monthly review meetings to ensure the care given is still appropriate to meet any changing needs of the residents. The manager has introduced the written monitoring and recording of specific areas of care into the rooms of very dependant residents. This should enable staff to closely monitor their well being, and take prompt action should their condition deteriorate. However, there was concern that staff are failing to record this information. The Manager and Operations manager were dealing with this at the time of the inspection. A resident with a pressure sore had a good plan of care to describe how treatment should be given. All the required aids and adaptations to support the healing of this wound were seen. There was evidence of visits by external health professionals, who provide specific health care services to residents. The community chiropodist said she visited residents regularly. Staff were helpful and kind, but the home always seemed to be short staffed. The home has a thorough procedure for the administration of medication to residents. On the ground floor where residential residents live, the senior care was seen dispensing medication, as the procedure requires. However, it was of concern that on the first floor the nurse in charge was not following the procedure nor the good practice guidelines issued by the Nursing and Midwifery Council. The trolley containing medication was left open on the corridor and unattended by the nurse. This presents a risk that any resident has access to unauthorised medication, putting their health at risk. It was also of concern that the nurse had still not administered morning medication due to residents at 10am by 12 mid day. This resulted in dosages of medication not being administer at the times prescribed and could have negative effect on the health and well being of residents. The manager was aware of this situation and appropriate action was taken. The procedure for the ordering and storing of residents medication was looked at and found to be satisfactory. A resident who had taken responsibility for her Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 14 own medication for a period of time, has agreed this was no longer possible, and agreed that staff would now provide administration assistance for safety reasons. The storage and administration of controlled drugs was looked at and was satisfactory. All staff that administers medication attend regular updates on safe practice. During the visit the inspector noted good and poor examples of promoting the dignity and respect for residents. One nurse entered a residents room without knocking, a care assistant talked to other staff whilst a resident was in a bathroom with the door open. She did not appear to understand that this was inappropriate and compromised the dignity of the resident. An excellent example of good practice was heard when carer spent a considerable time reassuring a resident with dementia, who was very upset. She demonstrated patience and understanding for the residents wellbeing. Staff would benefit from a retraining programme on understanding how to improve the delivery of care with a focus on dignity and respect to residents. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 15 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 group outcome is adequate. This judgement has been made because evidence was seen that: Residents have some choice as to how they spend there day. Activities take place each afternoon. The recording of social events for residents should be reviewed. Visitors are welcomed to the home. Food served to residents is nutritious, to help them maintain their physical wellbeing. Food service could be improved. EVIDENCE: Residents were observed being offered choice as to when to get up and where they wanted to spend their day. However, there was anecdotal evidence that some residents are encouraged by staff when to get up and go to bed. This should always be the residents choice, and not influenced by staff. The home employs an activity organiser who organises group activities on the ground floor and tries to spend time with people who stay in their rooms on a one to one basis. The recording of activities should be included in individual Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 16 care plans. This will provide opportunities for all staff to record any social activities that residents participate in. Generally the residents said staff are kind, they work hard, but they often had to wait for assistance. This was confirmed when I rang the buzzer on behalf of a resident requiring assistance. The buzzer had not been answered after ten minutes. This time delay is unacceptable. Residents comments included, “ they are always so busy, but we do have a laugh.” Another said “They are kind, but always in a rush.” Two residents completed the CSCI questionnaires during the inspection. Also a telephone conversation with a residents relative following the inspection visit confirmed the above comments and observations made by the inspector. A number of visitors said the home was nice and clean, that staff were always busy,but were friendly and helpful. The cook has experience of the nutritional needs of older people. In discussion it was clear she is committed to providing food that not only looks attractive but also has high nutritional value. New menus have been introduced and residents were consulted about the changes they would like. This is good practice. The home has two dining rooms, one on the ground floor, and the other on the first floor. The ground floor room is large and because of the flooring has an echo effect. The manager should consider how this room could be made more domestic in its appearance. The tables had clothes, serviettes, and a flower decoration. However there were no salt and pepper pots or fruit juice available. Lunch is served at 1pm.Residents were brought to the table a long time before the meal was served. The cook serves food to residents on the ground floor. A menu was on display. An example of good practice was noted for a resident who is blind. The cook spent time explaining where each portion of food was on the plate. The residents said the food was good, and they enjoyed their lunch. There was choice of cottage pie or meat. This was served with mashed potato, fresh vegetables and followed by home made rice pudding. Food for residents on the first floor is taken from the kitchen in a hot trolley. It was noted that this could present a health and safety hazard as the trolley is very hot. A risk assessment and hazard warning notice is required for this activity, to protect staff and residents from burns. The dining room on the first floor is domestic in type. The tables were fully equipped. Residents were chatting whist they enjoyed their lunch. Those resident who eat meals in their room are served after the main lunches have been served. It was observed that it was almost 2pm before some of Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 17 these meals reached the residents. The manager should review the mealtimes system to establish if it could be improved. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome group outcome is good. This judgement has been made as evidence confirmed systems are in place to protect residents from abuse, and encourage them or their relatives to make complaints. EVIDENCE: The complaints procedure is displayed in the entrance hall. A visitor confirmed that a complaint made to the manager had been taken seriously and dealt with effectively. All complaints are recorded. Evidence of this was seen. The inspector saw written evidence of good practice involving all relevant external agencies during the investigation into adult protection allegations. Staff would benefit from training in the protection of vulnerable adults to increase their awareness for the benefit of residents. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 19 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 and 26 Quality in this outcome group outcome is good. This judgement has been made based on evidence seen when touring the building. The environment was appropriate to meet the needs of the residents. The home was clean and free from odour. EVIDENCE: With the exception of a door wedged open to a lounge used as a smoking room on the first floor, the environment appeared safe and appropriate for the need of residents. The domestic staff team have had training in infection control and have NVQ qualifications relevant to their roles. The home was clean, tidy and free from odour during the visit. Acre Green Nursing Home DS0000001317.V297846.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 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 group outcome is poor. This judgement has been made as evidence confirmed: Staff are not working in a way that benefits the residents needs. Staff training takes place but there is a long way to go, there is a strong commitment from the new manager to making sure that the staff have the necessary skills, knowledge, and commitment to meet residents needs. Residents are protected by the homes recruitment procedures. Targets for care staff to achieve NVQ level 2 have not been met. EVIDENCE: The new manager has increased staffing levels. Despite this increase staff are not working in a way that benefits the needs of the residents on the first floor. A change to working practices has been introduced on the first floor. However, any benefits from these changes are lost because the nurses are not managing the shift effectively. This results in some care staff doing what they want, rather than what may be in the residents’ best interest. This shortfall in standards was identified in a previous inspection report. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 21 Communication between members of staff must be improved. The current lack of effective communication between members of staff is having a negative effect on the care of residents. The Manager and Operations Manager are currently working to an action plan to resolve these issues, but they were very apparent to the inspector on the first day of the visit. The recruitment and training files of two staff member’s were looked at. There was evidence of a robust recruitment process, to ensure staff were suitable to work with vulnerable adults. Staff receive induction training. Records of these were seen. Staff confirmed they had received training in safe moving and handling, and fire safety. The number of care staff with NVQ level 2 is three. This does not achieve the 50 targets. Acre Green Nursing Home DS0000001317.V297846.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, 33, 35, 36 and 38. Quality in this outcome group outcome is adequate. This judgement has been made as evidence confirmed: The new manager is focused on improving standards of care at Acre Green for the benefit of residents who live there. The organisation has robust systems to measure the quality of services delivered at the home. Residents’ financial interests are safeguarded. Staff receive one to one supervision. There was evidence of safe working practices. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 23 EVIDENCE: Ms S Hague is a registered nurse with experience of managing care of the elderly, both in a hospital and community environment. She has been in post since March 2006. She has yet to be registered, as the manager of Acre Green with the CSCi.She will be required to undertake a formal management qualification. This will complement her experience as a trainer for the protection of vulnerable adults. She has the skills and knowledge to lead the changes needed to improve standards at Acre Green A new position of care co-ordinator(deputy manager) has been introduced since the last inspection to support the manager on a daily basis. Ms Hague also has the support of a visiting Operations Manager. There was evidence of staff meetings, resident/relatives meetings. The manager conducts monthly audits on all areas of service in the home. The findings are share with relatives. Senior managers audit various aspects of the service during their monthly visits. The home has a robust procedure for managing residents personal monies held at the home. Staff confirmed they receive one to one supervision to discuss any concerns or training and development needs they may have. Prior to the inspection visit documents relating to health and safety maintenance were reviewed. It was noted that the 5-year electrical hardwiring certificate was out of date. The Operations Manager arranged that this work be done as a matter of urgency during the inspection visit. All other maintenance records indicated they were up to date. Acre Green Nursing Home DS0000001317.V297846.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 3 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 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 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 3 x 2 Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 25 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 Requirement Admissions to the home must comply with the registration categories on the certificate of registration issued by the CSCI. Care plans must show that residents personal preferences have been taken into consideration. Care plans must reflect that risk assements are reviewed. Those residents with low weight have an appropriate plan of care. Nurses must adhere to safe working practices when administering medication. The manager must ensure that the social needs of all residents are met. The manager must review and improve the current communication systems between staff to improve standards of care for residents. The home must have a minimum ratio of 50 Care staff with the NVQ award The manager must introduce training on protection of vulnerable adults for all staff. DS0000001317.V297846.R01.S.doc Timescale for action 30/09/06 2 OP7 12,15,18 30/09/06 3 4 5 OP9 OP12 OP27 13(2) 12 12 30/08/06 30/09/06 30/09/06 6 7 OP28 OP30 18 18 30/12/06 30/09/06 Acre Green Nursing Home Version 5.2 Page 26 8 OP32 9 OP33 10 OP33 11 OP38 12 OP38 Senior staff responsible for shifts must receive training to give them the management skills to ensure care is of a satisfactory standard (identified in the last inspection report.) 18(1)a,(1) Managers and staff must ensure c, (2)(3) that the home is run in the best interests of all the residents (identified in the last inspection report.) 35 In accordance with new legislation the providers must produce an action plan identifying their plan for improvements in the home. 23 The providers must ensure that the 5 year electrical hard wiring checks are completed as matter of urgency. 13 The heated food trolley must be risk assessed for safe use and include a hazard notice. 12,18 30/09/06 30/08/06 30/08/06 30/08/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3. Refer to Standard OP32 OP15 OP8 Good Practice Recommendations Managers of shifts should provide leadership and take more responsibility for ensuring systems are followed. The manager should review the existing systems for serving meals to residents. Staff on the nursing unit should spend more time with residents to meet their social and emotional needs. Acre Green Nursing Home DS0000001317.V297846.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Acre Green Nursing Home DS0000001317.V297846.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. 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