Inspection on 30/08/06 for Acres Nook

This inspection was carried out on 30th August 2006.

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

Acres Nook 23/06/08

Acres Nook 18/11/05

Acres Nook 08/06/05

Acres Nook 14/12/04

Acres Nook 19/07/04

Acres Nook 09/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Acres Nook Boathorse Road Kidsgrove Stoke-on-trent Staffordshire ST7 4JA Lead Inspector Mrs Yvonne Allen 2nd Inspector Mrs Lynne Gammon Key Unannounced Inspection 30 August 2006 10:30 X10029.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 Acres Nook DS0000026933.V307235.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 and Care Homes for Adults 18 – 65*. 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. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acres Nook Address Boathorse Road Kidsgrove Stoke-on-trent Staffordshire ST7 4JA 01782 773774 01782 777560 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) Modelfuture Limited, Ashbourne Limited, Ashbourne Consolidated Group Care Home 72 Category(ies) of Old age, not falling within any other category registration, with number (72), Physical disability (36), Physical disability of places over 65 years of age (48) Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 36 Physical Disability (PD) - minimum age 30 years on admission Date of last inspection 18 November 2005 Brief Description of the Service: Acres Nook is a purpose built care home providing both personal and nursing care and accommodation for up to seventy-two service users. The home can admit service users from the age of eighteen years. Acres Nook Care Centre is a two-storey property set within its own grounds. Accommodation is provided to both floors and the home endeavours to ensure that the ground floor is dedicated to older service users and the first floor to younger adults. A passenger lift and stairs provides access between the floors. Both service users groups have their own staff team. The majority of bedrooms are single and a small number have an en-suite facility comprising of a toilet and wash hand basin. Both floors have lounges, a dining room, assisted bathing and toilet facilities. The laundry and kitchen are sited on the ground floor. Externally, the home has enclosed gardens to the rear. There is a paved forecourt that is divided to provide a sitting area for service users and a small parking area. There is also parking to the rear of the property. The home is within walking distance of the main shopping area in Kidsgrove town and is on a main bus route into the city of Stoke-on-Trent. The fees for this home at the time of the Inspection ranged from £314.00 to £1070. Items not covered by the fees include hairdressing services, newspapers, toiletries, trips and holidays. This information was supplied by the home to CSCI on 29/9/06. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by two inspectors and took just under five hours to complete. key standards were assessed with each inspector looking at different areas. Evidence was gathered using the following methods – Tour of the home Discussions with staff, residents and visitors Discussions with the acting manager Examination of relevant records and documentation Inspectors were made to feel welcome and were given assistance where required. All but one of the key standards assessed were fully met. There were 2 requirements and 1 recommendation made as a result of this inspection. No immediate requirements were left. The manager has been referred to as “acting manager” for the purpose of this report as she is currently undergoing registration with the CSCI. The home continues to improve and develop and offers areas of excellence where some standards have been exceeded. What the service does well: The acting manager is very pro-active and works hard to ensure that individual residents maintain as much of their independence as possible. Individuals are able to take assessed risks in order to maintain links with the community and uphold their social interests. The staff at the home also help to ensure that the diverse needs of individuals are met, autonomy promoted and that care is delivered with dignity and respect. The activity co-ordinators offer an extensive activity programme, which is geared to suit the needs of individuals. The staff-training programme is effective and the staff team are competent, skilled and professional. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 6 Advice and treatment are sought from other healthcare professionals and there was evidence of good multi-disciplinary working. Residents’ comments included the following – “I am quite happy with all the meals.” “I always wanted to come here, after I heard the good reports.” “I am very happy with the activities and I like to help as much as possible when I am able.” “Yes I am happy with my meals but I would like spaghetti bolognaise occasionally.” “Resident is pleased with the cleanliness of the home and she has a comfortable bed.” 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. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following a thorough assessment of their needs and receive an individual contract following admission. EVIDENCE: Two residents were chosen at random to be case tracked, one elderly person and one younger adult. Examination of their individual plans identified that they had all undergone a full assessment of their needs prior to being offered a place at the home. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 9 The acting manager or one of the care managers at the home usually undertook this assessment. There was evidence of assessments having been carried out by funding bodies also prior to placement of the individual. Contracts were in place outlining the terms and conditions of stay. These were clear and concise. Comment cards received confirmed that residents were aware that they had received a contract. The home does not accommodate residents with intermediate care needs. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are set out with individuals and care is delivered with dignity and respect. EVIDENCE: Case tracking continued and the two individual plans were examined in detail. Personal care and nursing needs had been assessed and set out and included taking assessed risks. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 11 Discussions with residents confirmed that they were aware of their plans and the younger person attended her reviews. The older person was also able to attend his reviews. Where individuals could not attend reviews advocates or representatives were welcome to attend. There was evidence of good multidisciplinary working including all relevant professionals. There was evidence of residents being able to self medicate following a risk assessment. In one bedroom, however, an individual’s medication was left out and not locked away appropriately. This was addressed before the end of the inspection and appropriate action taken. Other records relating to medication were found to be in order. Those residents spoken to felt that the staff treated them with respect and that their individual privacy and dignity were upheld. Observation of care practices identified that diverse needs were catered for, especially in relation to helping residents with severe and restricting mobility problems. Not many written comments were received from residents and the answers ticked on the “Have your say about…” questionnaires were mixed, some positive and some negative. On average, the majority of residents were satisfied with the overall care provided. Comments received on the day of the field visit were positive and individuals felt that the home met their needs and that staff treated them with dignity and respect. GP comments indicated that they were satisfied with the overall care afforded to residents in the home. Comments received from placement officers indicated that they were also satisfied with the services provided by the home. There were some comments, which indicated that, on some occasions, the home might try and meet needs of individuals where they are unable, or no longer able to do so but, as one placement officer identified, “I have noticed gradual improvements taking place over time.” Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are able to exercise choice in relation to their lifestyles in the home and diverse needs are catered for. EVIDENCE: Continuation of case tracking identified that records had been maintained of individual participation in activities. Individuals had been assessed as to their wishes and abilities for activities and leisure pursuits. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 13 The record of activities was inspected. Examples of activities held on a regular basis were – bingo, quizzes, hand massages, art and craft sessions, karaoke, and special themed days for Easter, Valentine’s Day, Christmas, Bonfire Night and other annual celebrations. At the time of the visit the activity taking place with a group of residents was “Guess the celebrity” and they were observed to be enjoying this. Outings and holidays also take place. This had included a recent holiday to Blackpool. Residents commented that the activities in the home were “very good”. The residents also have their own committee and regular residents’ meetings are held. The last recorded were for 23/05/06 and 31/03/06. The minutes of these meetings were evidenced. Discussions held with the residents and staff confirmed that the spiritual needs of individuals were upheld wherever possible. Services and prayer meetings are held in the home on a regular basis. Individual residents are able to use the local facilities and, at the time of the visit, one resident was observed travelling to the local supermarket in his motorised chair. Mixed comments were received from residents in relation to the meals served at the home. One read – “I would be happy with smaller portions.” There was evidence of recent food quality audits having been undertaken, where a survey had been given to each resident. The response had been analysed and the menus changed accordingly. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be assured that any concerns they might have will be listened to and acted upon and that the systems in place at the home help to protect them from harm. EVIDENCE: There was a clear complaints procedure in place, which was accessible to residents, relatives and visiting professionals. This contained details of the local CSCI office. The manager maintained a log of complaints and the CSCI had received one complaint since the last inspection regarding respite care. This had been referred to the provider to investigate with a satisfactory outcome. Residents spoken to confirmed that they would know who to talk to if they had any concerns about the home. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 15 A comment made by a placement officer read – “I have worked with the home when complaints have been made and generally the agreed action plan has been followed through.” Staff spoken to were aware of the procedure to follow in relation to Protection Of Vulnerable Adults and staff training was given in this area. Staff are carefully selected to work at the care home and undergo required checks before they are offered employment. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment which is clean and well presented and which has been adapted to meet their individual and collective needs. EVIDENCE: All communal areas and a selection of bedrooms were inspected. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 17 The home was found to be clean and well presented. There had been some improvements made in relation to redecoration and refurbishment since the last inspection. The corridors on the second floor unit had been redecorated and new lighting provided. The hair salon and one of the bathrooms on this unit had been redecorated. The inspector was shown bedrooms which had been tastefully redecorated and refurbished and where individuals had chosen the colour schemes and materials used. Bedrooms were found to be homely, personalised and adapted to meet the needs of individuals. There was a new activities room provided. The dining room had been redecorated and new furniture provided. One of the small lounges on the second floor, which had not been used by the residents, had been made into a character bar room with tables, chairs and a bar. This was impressive and the staff are to be complemented on providing this facility for the residents. Residents spoken to were excited about the prospect of being able to go and visit the bar and socialise. The manager explained how the staff would monitor this facility once a licence had been granted. On the ground floor elderly care unit the dining room was in the process of being redecorated and refurbished. A replacement bathroom had been ordered. The ground floor would benefit from further redecoration and refurbishment and the programme needs to be continued throughout the home. The garden area had been tidied up and looked attractive with new plants and shrubs. Residents were observed to be enjoying the outdoor space at the time of the visit. There is a requirement to provide an action plan to replace the seals on the windows, which were observed to have blown. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are looked after by a dedicated, trained and competent staff team. EVIDENCE: Several staff files were examined at the time of the visit and personal training records were seen. All required checks had been carried out on staff prior to them being offered a position at the home and all necessary information was contained in the files. The same staff members were spoken to during the visit and they all confirmed the above. Staff confirmed that they had received induction training when they started to work at the home and that the manager had supported their training needs. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 19 They all confirmed that they received regular updates in mandatory training such as moving and handling and fire safety. NVQ training was ongoing at the home and staff had been supported and encouraged to develop their skills. At the time of the visit there was a total of 50 residents accommodated at the home with elderly residents accommodated on the ground floor and younger residents on the second floor. The manager works as supernumery and is supported by 2 qualified nurses – one working on each floor throughout each 24-hour period. 4-5 care assistants work on each floor throughout the day during the early shift then 3 on each floor plus one working a twilight plus 1 on at 6 am. There was a full time maintenance person on duty, full time administrator and sufficient numbers of domestic and kitchen staff on duty. The home also employed two dedicated activity co-ordinators. Comments received from residents and relatives in respect of the staff who work at the home were very positive. Discussions with staff members during the visit identified that these staff were dedicated, caring and professional. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and transparent way and in the best interests of the residents who live there. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 21 EVIDENCE: The CSCI were in the process of registering the manager at the time of the visit. Very positive comments had been received from both staff and residents in respect of the manager. They stated that she was supportive and accessible. It was apparent to inspectors that the acting manager had made a visible difference to the quality of services provided by the home since taking up her position. Regular meetings are held for residents and staff and recent ventures undertaken at the home evidence that the home is run in the best interests of the residents. Records relating to formal staff supervision were examined and found to be inconsistent. This area was in need of further development. Records relating to the maintenance of a safe environment were examined and found to be in order. The inspector was informed that the County Fire Safety Officer was due to visit the home on 18/09/06 to carry out a routine inspection. A copy of his report will be forwarded to the CSCI. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 22 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 x 2 x 3 3 4 x 5 x 6 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 x 21 x 22 x 23 x 24 x 25 x 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 x 34 x 35 x 36 2 37 x 38 3 Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 23 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 OP19 Regulation 23(2)(b) Requirement There is a requirement to provide an action plan to replace the seals on the windows, which were observed to have blown. The formal staff supervision programme must be stepped up and records maintained. Timescale for action 20/11/06 2. OP36 18(2) 20/11/06 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 OP19 Good Practice Recommendations To continue with the programme of redecoration and refurbishment particularly on the ground floor unit. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Acres Nook DS0000026933.V307235.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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