Inspection on 12/07/05 for Acre Green Nursing Home

This inspection was carried out on 12th July 2005.

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 11/07/06

Acre Green Nursing Home 30/11/05

Acre Green Nursing Home 13/01/05

Acre Green Nursing Home 03/08/04

Similar services:

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Snydale Care Home

Hawkhills

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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 Sue Dunn Announced 12 July 2005 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 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 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Highfield Care Management Limited Mrs Marilyn Cooper Care Home with Nursing 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2) of places Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13/01/05 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. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was announced, was undertaken by one inspector. The inspection started at 10.25am and finished at 7.35pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. An additional visit took place on 29.06.05 and some of the findings from that visit are included in this report. The home has undergone several changes in recent weeks due to change of ownership, a new manager and operations manager and the loss of the deputy who has been a constant factor in the home for several years. The manager is awaiting confirmation of registration and assisted with the inspection on this his first inspection since starting to work in the home. The home is currently advertising for a deputy manager. The inspector spoke to residents, visitors, staff members, the administrator and the operations manager. Records were inspected, including resident’s care plans and daily occurrence sheets and a selection of records. Staff training records and some care files were examined at the time of the additional visit. During the inspection 10 people evacuated from another home in the city were admitted to the home as an emergency. What the service does well: The standard of accommodation is high and rooms allow enough space for people to have their own furniture and personal possessions. Residents and visitors commented on the cleanliness and good odour control in the home. Staff were described as ‘kind and friendly’ and people looking round the home for the first time said there had been a warm welcome. Several of the experienced staff displayed their understanding and skills whilst working with people who had visual and mental impairments and dementia. They could benefit from more specialist training in this area of care. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There must be evidence to show that every resident or their representative has received and signed the terms and conditions of occupancy. Contracts must include the number of the room to be occupied Pre admission assessments must provide enough information to establish if the home can meet all needs. The home’s assessment must show, prior to admission, what resources, including human skills and resources, they will provide in response to those needs. This can allow time to make preparations for admission the for an initial plan of care. More could be done to assist new residents and their families during the early days of admission to reduce anxieties experienced by people who are adjusting to a new environment and assure them of their rights. Care plans must include the views and preferences of the resident, and their family if appropriate, and be more descriptive about how the care is to be given. Care plans must include guidance on effective methods of communication. Spiritual, social and recreational care plans must be more clearly recorded to reflect the quality of life experienced . Care staff on the nursing unit who have most direct contact with residents should be given more responsibility for recording daily events in care files to ensure information is not overlooked. There must be more attention given to details of care which maintain dignity and self esteem such as teeth, nails care wiping spilt food from mouths and chairs. Rotas must provide an accurate record of the named staff working on every shift. Staff deployment and breaks must take account of the needs of residents first and the social needs of staff second. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 7 The organisation should take action to deal with poor attendance and high levels of sickness amongst staff as this is affecting morale in the rest of the staff team. Staff training must be ongoing, meet training targets and keep pace with the needs of residents to ensure that people are competent. 50 of staff must have the NVQ award. The target date for this to be achieved has passed. 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 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home provides written information about the facilities and services and makes people feel welcome on their first visit. This information should be discussed further after admission and every resident given a contract of terms and conditions of occupancy to ensure they understand their rights and responsibilities. The pre admission assessments must be more detailed if the home is to give assurances that they can meet more than basic physical care needs. The staff worked well to try to settle a group of people admitted due to a local emergency. EVIDENCE: The home has a statement of purpose and a guide to services. This is given to anyone considering the home. One person had found the need for admission to the home distressing and had not absorbed the information. Other people did not understand such things as the complaints procedure and what a key worker was. More time should be given to discussing the contents of the written information once people are admitted as some people are unsure of the ‘rules’ and their rights. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 10 The only signed contracts seen were for people who were privately funded. The newly organised company has produced contracts which have not yet been put into use. These do not include a space for specifying the number of the room to be occupied. Pre admission assessments had been undertaken but the quality of information on these, from other agencies and done by the home, with the exception of one which had a supporting letter attached, was very limited and did not provide a picture of other than physical and nursing care needs. The manager acknowledged that these could be improved. Pre admission visits to the home were described as welcoming and friendly though one person did feel she had been ‘dumped’ and she had little say in the decision. Ten people with dementia were admitted as an emergency following their evacuation from another. The operations manager and staff team as a whole dealt with the situation professionally and with good humour and some good practice was seen. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Care plans were extensive and health care needs were met. However, there was not enough detail to show how the personal, emotional and social care needs of residents were met. There was a lack of attention to detail in the personal care of some people who were totally reliant on staff to maintain their self- image. Residents and their families, must be involved in the formulation of the plan of care with evidence that their views have been considered. Shortfalls in communication between different groups of staff led to some care needs being overlooked, particularly on the nursing unit where the recording of information is left to the nurses. EVIDENCE: Four care files were inspected. The extensive number of care plan sheets had been completed in every file but on closer examination were found to lack detailed guidance on how staff should work with each resident. The care plans did not show any evidence that the resident or their family had been a part of the process and there were discrepancies between what a carer said and what had been written in the care plan. This appeared to have been taken from information sent from the hospital. This care plan did not include any plan for maintaining continence and a broken raised toilet seat required for the promotion of continence had not been replaced for over a week. None gave Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 12 any detailed guidance on methods of communication to be used. Individual care staff had devised their own ways of communicating but there was no system of sharing the effectiveness of their methods with other staff through the care plan. Care plans and daily records on the first floor unit were written by nursing staff therefore some of the details describing the quality of life for residents were overlooked. A risk assessment indicating the possibility of choking did not include an action plan of what to do should this occur. There was no evidence to show if staff had received training on what to do if someone was choking. Health care needs were being met with support from other professionals. The tissue viability nurse had given advice on one persons care, a psychiatrist was visiting and one person described the GP as ‘very helpful’. None of the people in the home manages their own medication. A care worker was observed administering medication and explaining to the person receiving it what the medication was for. A member of staff who has not had any update training on medication for 4 years described how she would use the medication reference book for more information about any unfamiliar medication. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Social activities and meals satisfied the needs of most residents who appeared to limit their expectations to what was provided. Social contact and stimulation on the nursing unit was very limited and is an area needing further development. Care plans should show how the home matches daily routines and social events to each person’s expectations and preferences. EVIDENCE: Care files did not give any guidance on the spiritual needs, lifestyles, interests, and preferences of each resident. Activities were rather ‘hit and miss’ and left to the imagination of the activities coordinator who single-handedly does a good job. On the day of the inspection she was working with small groups of people in the ground floor dining area. Some were painting and others were playing dominoes. All appeared to be actively involved. Some time was spent talking to people on a one to one basis. She described the difficulties of motivating people in the nursing unit and said she tries to spend a little time just chatting to people in their rooms. The value of this goes unrecognised as ‘activity’ but should be recorded as such in the daily logs. She confirmed that activity coordinators from other homes in the group are starting to meet on a regular basis to share ideas. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 14 People were seen to have visitors and were able to make use of the outdoor courtyard but staff said that there was little opportunity for taking people out in wheelchairs as had been the case in the past. The midday meal was sampled in the ground floor area. The food was hot on arrival at the nicely set out tables and offered two choices of main course and dessert. One option, a packaged fish cake was mediocre and uninteresting, as acknowledged by the cook, but overall residents were satisfied with the food. One commented ‘you may get better food in an hotel but you couldn’t beat the service’. He confirmed that ‘get togethers’ are held periodically to ask for suggestions about menus and other aspects of life in the home. Round soup spoons had been given as dessert spoons making it difficult for some residents to get food to their mouths without spilling. This has been noted on previous inspections. The inspector was informed that some residents are left with food around their mouths after meals but this was not observed. A member of staff was doing a good job of describing the layout of food on the plate of a non sighted resident. Milk shakes and ice cream cornets were available as the day was very hot. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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 standard(s) 16,18 There is confidence that complaints to the manager and operations manager will be handled appropriately. Staff need more training to understand their own responsibilities in handling complaints. The manager and staff would benefit from Adult protection training and whistle blowing policies. EVIDENCE: The home has a complaints procedure and the manager aims to rectify any complaints or concerns which are brought to his attention regarding care practices. However, complaints about a broken raised toilet seat brought to the attention of staff, which could easily have been resolved, had not been satisfactorily dealt with. This led to a resident’s care needs not being met for several days and a loss of confidence by relatives. Two complaints were recorded in the complaints log since the last inspection, both recently. One handled by the manager and the other investigated by the CSCI. One concerned a missing item of property and showed the action taken. The other, which was anonymous, questioned the lack of training and knowledge of staff and the home’s ability to meet the needs of a recently admitted resident. Staff felt their concerns were not being listened to. The complaint investigation found elements of the complaint were partially upheld and led to some requirements and recommendations being made. These concerned the quality of pre admission assessments and the lack of guidance contained in care plans as discussed in standards 4 and 7. Staff training had not kept pace with the changing needs of residents and there was a reluctance amongst some staff to accept guidance from the nurses. The Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 16 operations manager has had a meeting with the staff team and is to send a written action plan formed by the manager and herself to resolve the matters. Some of the issues identified in the investigation had already been acted upon at the time of the inspection. Visitors said they felt the manager was approachable and they would have no problems bringing their concerns to his attention. One person expressed concerns about making complaints which might be regarded as ‘petty’. These concerned care practices and were taken seriously by the manager. However, other matters discussed with unspecified staff had not been acted upon. The manager has only recently been made aware of the adult protection procedures operating in the area. He has been advised to contact the adult protection team for advice on his own behalf and concerning information which arose during the inspection. A member of staff was clear that she would immediately report any bad practice therefore it was of concern to hear of two related incidents involving careless handling which had not been brought to the attention of the manager. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 The home provides a pleasant, clean, comfortable and safe environment with sufficient space for residents to have their own belongings around them and use the outdoor areas freely. More attention should be given to routine daily cleaning of wheelchairs used by residents in the interests of hygiene and dignity. EVIDENCE: The buildings and grounds have been well maintained by a regular maintenance person. Communal areas are generous. Furnishings, fittings and décor are pleasing to the eye and have been replaced as required to retain a good standard. A resident commented ‘the place is always clean, there is never an odour, which is a lot to be said for a place with so many sick people’. A visitor also commented on the cleanliness of the home. This was let down by a comment about the wheelchairs which were described as frequently ‘mucky’ with food which had not been wiped off after meals. A proportion of residents on the first floor prefer to remain in their rooms. Many of these had been made ‘homely’ and comfortable with personal Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 18 possessions and furniture. When one person’s room was admired for how pleasant she had made it she responded ‘you have to don’t you as it’s the only home you’ve got’ Large raised wooden numbers had been made for two bedroom doors to aid the occupants with visual disabilities to identify their rooms. Word cards had been obtained for one resident to aid communication. The home had sufficient specialist equipment to be able to accommodate the needs of two of ten residents admitted as an emergency from another home. All rooms are en suite but communal bathrooms appear institutional and not designed to make bathing a pleasing experience. Clothing and bedding appeared well laundered though relatives spoke of having to go to the laundry themselves to retrieve clothing to ensure residents had sufficient clothes in their rooms. This task should be the responsibility of key workers. Clothing has in the past been roughly labelled with unsightly felt pen with complaints items have gone missing. It is suggested that the home find a supplier of woven labels which, if purchased in bulk, will reduce the cost to residents whilst ensuring their clothing is appropriately labelled. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Attendance at work and staff time management must be addressed to ensure that there are enough staff to meet service users needs. A training programme which keeps pace with the care needs of the people in the home is required if staff are to build their knowledge and skills to give good care. EVIDENCE: The home had a total occupancy of 38, 13 of whom were on the residential unit. The rotas aim for 8 staff in the mornings and 6 in the afternoon. Two of this number work on the ground floor residential unit. The activity coordinator and domestic staff are in addition to this during some parts of the day. The rota, which is laminated, had to be cross referenced with the time sheets in order to obtain a true record of who worked and when. The manager was described as sympathetic to the needs of staff who may need to change shifts for domestic reasons but some staff were said to take advantage of this and change shifts without approval. Both visitors and staff feel there are not enough staff. Residents were said to be left for long periods unattended in the lounge and staff said they no longer have the time to take residents out. The manager and staff spoke of people who phone in sick at short notice or fail to comply with the sickness procedures. This has been an ongoing problem which undermines the commitment of other members of the staff team who were critical about the Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 20 way it is handled. The previous Sunday was an example of this and had been described as ‘very hard’. There were concerns that all staff congregate down stairs at the weekends and regularly go for their breaks together leaving staff shortages in some areas. A nurse confirmed that staff were reluctant to go for breaks unaccompanied. The staff felt that the home gives good care and that they work to the best of their abilities, however training has been limited to what was provided in house by the previous manager and deputy and staff who wish to do the NVQ award have not had the opportunity. The recent complaint was because some staff felt didn’t feel they had not been trained to care for a recently admitted resident. The future for staff training looks more promising. The training manager has visited the home and eight staff have been enrolled for NVQ. Some staff are doing a basic dementia training given by the manager of one of the other homes. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36,38 The home has a manager and operations manager who are starting to provide the necessary leadership and guidance for the home to operate in the best interests of the residents. Health and Safety records were well recorded and maintained and fire safety drills have taken place. However, the lack of staff training and examples of poor time management within the staff team does not inspire confidence that the safety and welfare of residents has been protected at all times. This will be monitored before the next inspection when it is expected the training programme will be well underway. EVIDENCE: The home benefited from stable management over the past couple of years. Recent changes have led to some unrest in the staff team. However, the Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 22 manager, who is new to the home, has the necessary qualifications for the job. His registration assessment has been carried out and he has been recommended for registration as ‘a fit person’ subject to a satisfactory CRB check by the CSCI. Past knowledge of the home has shown that a strong, firm, but fair, leadership approach is needed across the seven day week to ensure care is consistent and in the best interests of service users. A ‘them and us’ attitude as described by nurses and care staff and the lack of clarity in care plans does not ensure the interests of the residents always come first. The home is currently advertising for a deputy manager. The manager has started one to one supervision with staff which has covered some policies and identified some training needs. As this becomes established it should also be used to discuss the statement of purpose and examine a selection of the care plans with key workers. Visitors and residents spoke of the kindness of staff and examples of good practice were observed during the inspection. Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 3 2 x x 3 x 2 Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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 OP2 Regulation 5 Requirement There must be evidence to show that all residents must have a contract which makes clear the terms and conditions of their occupancy and the responsibilities of both parties Pre admission assessments must be detailed enough for the home to show how it can provide for the overall needs of each person as well as their physical care Care plans must be more detailed and include the views of the residents or their representatives. The care plan must set goals which cover all the basic principles of care privacy, dignity, rights,choice, independance and fulfillment. The care plans must be used as a working document to provide guidance for everyone giving the care and be open to review and amendment as care needs change and staff gain more knowledge of the person. Risk assessments must be followed by a detailed management plan to minimise risks without restricting rights. Staff must be trained to know Timescale for action 30.09.05 2. OP4 14 30.09.05 3. OP7,OP12 12,15,16 By 31.10.05 4. OP7 12,13,15 30.09.05 Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 25 5. OP15,OP12 12 6. OP16 18,22 7. OP18 13,18 8. OP22,Op26 13,23 9. OP27,OP28 ,OP38 OP30,OP38 18 10. 18 11. OP33 12,18 12. OP27 18 what action to take in the event of an emergency. Staff must ensure that the dignity and self esteem of residents is promoted at all times Staff must be trained to take responsibility for ensuring any complaints are dealt with to the satisfaction of the complainant The manager and staff must be familiar with the local adult protection procedures and whistle blowing poicies All staff must take responsibility staff to ensure that spilt food is wiped up after meals and not left in wheelchairs There must be enough staff available at any time to ensure residents are safe and not left for long periods unattended All staff must be trained and work to a level which keeps pace with the needs and safety of the residents in their care. The deployment of staff must be done in a way which recognises the best interests of the residents come first. 50 of staff must have the NVQ award ongoing 31.12.05 30.09.05 Ongoing Ongoing 31.12.05 31.08.05 31.03.06 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. Refer to Standard OP7 Good Practice Recommendations All staff should have an opportunity to share experiemces of what they have found improves the quality of life for a resident so this can be incorporated into the plan of care. The key worker system should be used effectively to ensure residents have everything they require Any activity or social contact time should be recorded 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 26 2. OP12 Acre Green Nursing Home 3. OP26 Residents should be encouraged to use some of their personal allowance for the home to purchase woven name labels.This will avoid the indignity of having clothes marked with unsightly felt pen and reduce the risk of misplaced clothing Acre Green Nursing Home 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds, West Yorkshire, 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 20050712 J52 S1317 Acre Green V204261 Stage 4.doc Version 1.30 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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