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

This inspection was carried out on 5th July 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

Acre Green Nursing Home 11/07/06

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 Paul Newman Key Unannounced Inspection 9:30 5 and 6th July 2007 th 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.V336400.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.V336400.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 acregreen@schealthcare.co.uk 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 vacant post 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.V336400.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 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 £397- £496. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection during the site visit July 2007. Acre Green Nursing Home DS0000001317.V336400.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. The last inspection was carried out in July 2006. This report is of a key inspection, made on an unannounced basis. One inspector made two visits to the home on consecutive days and spent a total of 13 hours on site. Key inspection reports are available on the CSCI website. The inspection process is ongoing and the home has been monitored since the last inspection through information that is required to be sent to the CSCI about significant events, complaints and regular monthly reports about the conduct of the home carried out by the provider. About two months before the inspection visit, the Provider was sent an Annual Quality Assurance Assessment (AQAA) to complete and this was returned promptly. This contains a lot of information that helped in planning the site visit. Survey questionnaires were also sent out and there was a small return from relatives, people using the service and visiting healthcare professionals. This also helped in planning areas to focus attention on the site visit. During the site visit records were checked, a tour of the premises was made and some of the staff on duty were spoken with. Several residents were spoken with including some who had lived at the home for a lengthy period and some who had recently arrived. Several people who were visiting residents were spoken with. On the second day a focused observation was made of staff at their work on the ground floor and first floor. This was done over a four-hour period beginning at the start of the early shift at 7.30am. This was specifically done to gain a better understanding of what it is like to live in the home and assess whether people using the service are receiving good quality care. Verbal feedback was given to the Operations Manager and the Manager at the end of the second day. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Acre Green Nursing Home DS0000001317.V336400.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 Acre Green Nursing Home DS0000001317.V336400.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 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People who may use the service and their representatives have the information they need to choose a home that will meet their needs. Peoples’ needs are properly assessed before admission. EVIDENCE: The current statement of purpose and service user guide is being reviewed. The registration certificate was reviewed and discussed during the site visit in line with changes the CSCI wants to make. Account will be taken of this in the evaluation of the statement of purpose. Information currently provided meets the standard and provides people with accurate information about the services provided. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 9 From the discussions and case tracking that was carried out that included checking four case files it showed that the manager carries out most preadmission assessments of people before they are admitted to the home. The pre-admission process is thorough and includes a summary of the main issues, family circumstances and any specialist equipment that might be required. Where possible the person who intends to use the service visits the home but where this is not the case, their family or representative always visits to gain information. One relative said that she visited the home without a prior appointment feeling that this was the best way to see each home that she was considering. She felt that the staff spent plenty of time showing her (around?) round and explaining things and that she was given the homes brochure. She said this was more positive than the approach taken by other homes and on the basis of what she saw and was told decided that her Mother would be best cared for at the home. She remains pleased with the care provided. Acre Green Nursing Home DS0000001317.V336400.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 and 10. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The care plans provide clear and detailed instructions for staff to follow making sure that health and personal needs are met. The people at the home are treated with respect and dignity. EVIDENCE: A selection of four individual case records was looked in detail and the care of those people case tracked. Since her arrival at the home in March this year, the manager has prioritised some areas of work and part of this has been a focus on care plans. All people living in the home have been subject to a review that relatives and other people involved have been invited to. The manager has experience of and qualifications in the care of people with dementia. She has provided Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 11 training for staff in care planning and staff spoken with said that they had felt this valuable and could see the benefits of making the plans far more person centred. Examples of this were seen in the written plans of each file that was checked. The individual records included an overview of the main areas of support needed that were identified from the pre-admission assessment. Specific care plans provided the detail of how the person’s care needs can be met and the developments encouraged by the manager identify much more detail of the individual’s personal preferences. Each of the care plans had been evaluated on a monthly basis and there were examples of this being sooner if a new need was identified and care need had changed. The surveys that were returned and the conversations with relatives showed that people feel that staff keep them up to date with changing care needs and the files showed signatures to show that the care plan had been explained and agreed. The language was straightforward and easy to understand. A full range of risk assessments were carried out and included risk assessments for mobility, falls, manual handling, nutrition, continence, and in one person’s case a risk assessment for going out independently. These were up to date with plans in place of how to manage any identified risk. Changes in condition were documented and monitored and where there was a need to seek medical advice this could be tracked. There is good overview monitoring conducted by the manager. For example, review dates are set by the manager and there was evidence in the files of her checking these had been completed and where necessary making comments or seeking clarification. People are weighed each month and the manager has developed an overview chart so that she can monitor individuals’ weight loss and gain. Medication systems are good. There is a medication administration check done at each shift handover. This will identify any errors in recording and makes sure that people have had their prescribed medication. There are monthly audits and stock checks. Drugs are stored securely and the nurse was seen to taking the necessary care in administering the correct drug to people and it was good to see that the nurse used this as an opportunity to have a conversation and check out any problems and to give reassurance. Staff were knowledgeable about the people they care for, could put names to faces and knew which rooms people occupied. They were observed and overheard to be cheerful and friendly and to spend time communicating with people. It was clear from overheard conversations that people were given choices and able to make decisions about their daily lives. Observations clearly showed the commitment of the staff to treat people with respect and make sure that they were dignified in the way they dressed and looked. People looked well cared for. Attention was given to make sure that Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 12 people were properly assisted and where personal care tasks were involved staff made sure that doors were closed and that people had the privacy they needed. One member of staff was observed caring for a person who had clearly become disorientated and managed the situation with skill and great consideration for the individual. In the conversations with relatives and people living in the home, there was plenty of praise for the staffs’ caring qualities, but also an acknowledgement that staffing levels have been difficult and have fluctuated and this has affected service delivery. See the later sections on daily life and staffing and how the manager and line manager are addressing this. Acre Green Nursing Home DS0000001317.V336400.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. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. Peoples’ social expectations are met. Staffing levels can affect peoples’ ability to exercise choice in their daily routines. People living at the home are provided with a varied and nutritious diet. EVIDENCE: 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 home has taken on the recommendation made in the last inspection report about recording activities. There is now a central file so that an overview can be made and individuals’ activities are now recorded in the care plan. People said that the activity organiser ‘is great’ or ‘lovely’ and one person talked about how she had been encouraged in card making, something she had not done before but now really enjoyed. Southern Cross has a mini bus that homes in the region can book and use but this was not previously Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 14 done on a regular basis. This is now being used consistently and there had been a recent trip to Roundhay Park. The office used for the inspection visit was adjacent to the main entrance and a regular flow of visitors could be seen throughout the time spent at the home. Those spoken with said that they felt welcome in the home and it was clear that they felt the manager was approachable. The home has links with local schools and churches, and a communion service is held each month for those people wanting to take part. Southern Cross has introduced new ways of menu planning and nutritional analysis specifically for older people. The manager and chef have been trained in the use of a software package called NUTMEG - a database of nutritional menu planning and nutritional analysis that also includes recipes. Since that point, menus have been reviewed and revised and the system was demonstrated during the site visit so that the nutritional value of the current menus could be seen. This does not exclude the possibility for people to make specific requests, express their personal preferences or the home meeting any special dietary needs of an individual. Choice is available at all mealtimes and one person who lives at the home said that they have requested alternatives above this. The manager has encouraged dining rooms to be set more attractively and has also made sure that snacks are provided more flexibly with a bigger range of ‘nibbles’ and cakes etc., fresh fruit and alternative drinks. The people spoken with said that the chef was good and ‘put herself about’ to make sure that things were alright. They did however comment on the fact that the home is currently without a weekend chef and the food can be variable. Attempts are being made to make an appointment. With regard to choice, over the course of time, there have been indicators that staffing levels were not always maintained as they should be. This was the reason for more focused observation on the second site visit. Conversations with a district nurse, staff and people living at the home clearly showed that there are times when choice for people living in the home for things like getting up time or personal care may have to wait. People accepted that there is always an element of this in group living, but even though there was no evidence that peoples’ healthcare needs are not being met, inadequate staffing levels affect the quality of their lives. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There is a clear complaints procedure available to the people at the home. The people who live at the home feel confident that they will be listened to and that appropriate action will be taken when necessary. There are robust adult protection procedures and staff have received training. People can be assured that they can feel safe at the home. EVIDENCE: The home has a clear complaints procedure that is displayed in the entrance hall and also in the service user guide. A file of complaints is kept and included the records of five complaints received at the home since the last inspection. The records demonstrated that complaints are taken seriously and dealt with appropriately. The Commission has received two recent anonymous complaints that were referred to the operations manager and manager and the issues raised were subject of attention during the site visit. The manager has held a relatives meeting since her arrival and has also introduced a weekly ‘surgery’ to see people living in the home or their relatives. One relative who visits on a daily basis said that the manager was Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 16 approachable and always prepared to listen, and felt that she was trying hard to put things right. Adult protection training is provided and the manager is familiar with Local Authority Procedures. In addition adult protection is included in National Vocational Qualification (NVQ) training. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. People live in a safe and well maintained environment. EVIDENCE: The home has a six monthly programme for housekeeping, maintenance and redecorating. This was made available. At the time of the inspection the maintenance person employed at the home was redecorating part of the first floor corridor. The rooms seen were personalised and very comfortable with good quality furnishings. There is a good range of specialist equipment in use for the highly dependent people who live at the home and staff were observed moving and handling appropriately. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 18 The home is well situated for local services but it has some problems with people cutting through the grounds that could present security problems. This was discussed with the Operations Manager and there is a commitment to provide a security gate and some CCTV for the outside areas of the home. There is also a commitment to provide a shower facility not currently available for people living in the home. Odour control was good as was the general cleanliness of the home. One of the housekeeping staff team was spoken with and said that there was a good team spirit and commitment to high standards. The team has worked together for a good period of time and have National Vocational Qualifications (NVQ) in housekeeping and completed and updated other relevant training. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. There have been times when the numbers of staff on duty have been insufficient to meet the needs of the people living at the home. Staff receive the training they need to do their job. Robust recruitment procedures protect the people living at the home. EVIDENCE: There had been indicators from complaints and surveys that were returned that staffing levels had not always been maintained. Over the two days in the home, discussions with staff, people living there, a community nurse and visitors confirmed that this was the case. There was a strong feeling from all quarters that there are some staff who ‘let the side down’ and call in sick at the last minute, a good deal of this being at weekends. One member of staff said ‘normally after a good night out’, and another said ‘some staff take the mick’. This was discussed with the manager and operations manager. There are two strategies to manage this. The first is to fully implement the company sickness monitoring policy that had not previously been done. The second is to Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 20 develop staff who are in a senior capacity, nurses and senior care assistants, to take responsibility for the situation and be more proactive in sorting these situations out by getting additional staff in for duty rather than just accept that this is the way it is. Since the new manager started there has been a recruitment drive that has been successful and she feels she is now at the stage where management strategies will begin to kick in. It was clear from some of the ‘throw away’ comments made by one or two staff that they are not happy, but all of those staff seen individually said that they had no issues with the way the manager was dealing with things. It was good to see the level of support that the manager is being offered by the operations manager in seeing things through and challenging poor staff performance, lack of loyalty to their colleagues and the people they care for. The manager and operations manager have agreed to keep the CSCI informed about how things develop. Over the two days of inspection the home was working with sufficient numbers of staff on duty. Observations showed relationships between staff and people living there to be good. There was plenty of good humoured and friendly banter. The morning routine was busy, but staff made sure that people were treated sensitively and that they were afforded the privacy and dignity they needed. There was a good deal of praise for the caring qualities of the staff from people being cared for and visitors spoken with. With regard to staff training the manager has conducted a training needs analysis and the training matrix seen on the day of inspection showed that she had identified what needed to be done, who needed what training and there was a programme in place to address this. Whilst the home has not achieved targets for numbers who should be NVQ qualified, there are sufficient numbers currently enrolled and working on qualifications for the home to achieve targets. The personnel files of three staff were checked to make sure staff are properly recruited and the necessary references and checks are made. These were well organised and had all the necessary documentation. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The home is well managed. The interests of the people who live there are seen as very important to the manager and her staff. Regular auditing and checking of facilities, equipment and services make sure the home is a safe place to live. EVIDENCE: A new manager was appointed in March 2007. She must now make application for formal registration with the CSCI. She has good experience in caring and managing care homes and has relevant qualifications. It is clear Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 22 she was not happy with some of the things she found and has begun to address these with the passion for high standards of person centred care that was acknowledged in the home she previously managed. Although not a qualified nurse, she has access to clinical support through the company. She has clear ideas about how care should be delivered and high expectations of her staff team. Some staff practices have been challenged but staff spoken with were beginning to understand ‘where the manager is coming from’, some of them saying it was ‘much needed’. All staff should take a step back and think about the improvements that are being sought and support the manager. Staff meetings are being held, individual supervision sessions are up and running and a relatives meeting has been held to talk about the changes that the manager is seeking. The manager has developed some good internal auditing and checking systems that include care plans, weight checks, medication audits, bed rails, and accidents. There has been an overall reduction in accidents over the last three months. The company conducts regular satisfaction surveys and bi monthly audits of the home and the operations manager carries out monthly visits and checks on a range of aspects that are formulated into a monthly report on the conduct of the home that is sent to the CSCI. Records are kept of money held for safekeeping and people can access their money at any time. There was evidence of this when a person wanted to go out to the local chemist to buy some toiletries. The current arrangements do not meet requirements because peoples’ personal money is held in one bank account that gains pooled interest from the bank. This is however noted in the service user guide. It is known that the company has now secured the services of one high street bank so that all people will have individual accounts that gain interest. Because this has been arranged no requirement will be made in this inspection report. The pre-inspection information demonstrated that safety checks are made of the facilities, equipment and services on a regular basis and during the inspection fire safety records and accident records were checked. Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 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 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 3 13 3 14 2 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X X 3 Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 24 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 OP14 Regulation 12 Timescale for action The registered person must take 01/09/07 steps to make sure that the people living at the home are able to consistently enjoy levels of personal choice and control of their lives according to their personal preferences. This should make sure that those living at the home and their relatives are happier that the care provided reflects their preferred way of living. The registered person must 01/09/07 make sure that staffing levels are consistently kept at levels that do not affect the quality of life of the people living at the home. This should make sure that those living at the home and their relatives are happier that the care provided reflects their preferred way of living. The manager must make a 01/09/07 formal application to be registered with the CSCI. Requirement 2 OP27 18 3 OP31 9 Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 25 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 OP27 Good Practice Recommendations The manager and line manager should continue to address staffing problems through the company sickness monitoring policy, through formal supervision and where necessary disciplinary procedures. All staff should support the important changes being introduced by the manager that are designed to improve the quality of life of the people living at the home. 2 OP32 Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Acre Green Nursing Home DS0000001317.V336400.R01.S.doc Version 5.2 Page 27 - 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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