Inspection on 14/05/07 for Acton Care Centre

This inspection was carried out on 14th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Acton Care Centre 18/09/06

Acton Care Centre 15/12/05

Acton Care Centre 13/06/05

Acton Care Centre 13/12/04

Acton Care Centre 07/06/04

Acton Care Centre 29/07/03

Acton Care Centre 23/06/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Acton Care Centre 48 Gunnersbury Lane Acton London W3 8EF Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 11:00 14th & 15th May 2007 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 Acton Care Centre DS0000034968.V336574.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. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acton Care Centre Address 48 Gunnersbury Lane Acton London W3 8EF 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) 0208 896 5600 0208 992 7116 Vintage Care Ltd. Mrs Sujjata Singh Care Home 125 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Terminally ill over 65 years of age (0) Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is registered to provide nursing care for 71 service users over the age of 65 of which 20 service users may be terminally ill, plus nursing care for 54 service users with Dementia over the age of 65. The home must ensure that staff working with terminally ill service users are Registered Nurses with appropriate post qualification training in the care of terminally ill. Five (5) service users between the ages of 55 and 65 years can be accommodated. These are to be included within the total number of 125 beds. The home must inform the CSCI when a service user(s) no longer resides at the home. Staffing levels must be kept under review in line with dependency levels of the service users to include those with palliative care needs. 18th September 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Acton Care Centre was registered in March 2003 to provide nursing care for 125 service users over the age of 65. The home provides 71 beds for general care and 54 beds for dementia care. It is a purpose built home with modern amenities close to Acton High Street set on the site of the old Acton Hospital. The home is able to access other health care professionals to supplement the nursing care already provided. The home has a large car park at its front and landscaped gardens at the rear of the building. At the time of inspection there were 102 service users accommodated at the home. The fees charged range from £642 to £820 per week. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 28 hours was spent on the inspection process and two CSCI Inspectors conducted the inspection, which was conducted over 2 days. A tour of the home was carried out, and service user plans, medication records, management records, training records, staff employment records, administration records, maintenance and servicing records were viewed. The pre-inspection questionnaire has also been used to inform this report. 15 people living at the home, 12 visitors, 15 staff and 2 visiting healthcare professionals were spoken with as part of the inspection process. 31 completed CSCI questionnaires received from people living at the home, visitors and a healthcare professional have also been used to inform this report. It must be noted that it is not always easy to ascertain the views of people living with the experience of dementia. The term ‘service user’ refers to a person living at the home. What the service does well: What has improved since the last inspection? Staff had received training in dementia care, to provide them with the knowledge to care for people living with the experience of dementia effectively. Risk assessments for falls were being fully completed and all documentation Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 6 updated following any falls. Bedrail risk assessments had been completed and written consents obtained. Improvements have been made in the management of medications. There were no obvious issues with storage. Overall the staffing provision is appropriate to meet the needs of the people living at the home to include nursing, care and ancillary staff, and the staffing is being kept under review. Staff employment records were up to date and action had been taken to ensure all checks had been carried out. 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. Acton Care Centre DS0000034968.V336574.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 Acton Care Centre DS0000034968.V336574.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to live at the home are fully assessed prior to admission, to ensure the home is able to meet their needs. EVIDENCE: Pre-admission assessments were viewed on each unit. These were comprehensive and gave a good picture of the persons’ needs, so the home could ascertain if they were able to meet them. Copies of Social Services and Primary Care Trust care needs assessments were also available. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is now evidence of input from people living at the home and their representatives in the service user plans, thus care needs are discussed and identified. However, some of the service user plan documentation was incomplete and therefore did not always give an accurate picture of each persons needs. Systems for the management of medications are good, thus safeguarding people living at the home. Staff care for people in a gentle and professional manner, respecting their privacy and dignity. End of life needs are discussed and planned for, thus ensuring the wishes of the individual and their families are respected. EVIDENCE: Two service user plans were viewed on each unit. Following a satisfaction survey carried out by the home the need for regular reviews of care for individuals had been identified. As a result a review is carried out for each person living at the home every 4-6 weeks and a record made. There was evidence of input from people living at the home and their representatives in the service user plans on each unit. The documentation had been reviewed Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 10 monthly and whenever a persons’ condition changed. Risk assessments for falls were in place and for one person who was case tracked by one Inspector the records had been fully updated following a fall. Donald Sword unit – Some of the healthcare documentation had not been fully completed or an inaccuracy in scoring on assessments was identified and this was addressed at the time of inspection. Garden unit – for one person who had lost weight there was no action recorded in the care plan, however the daily record reflected that the dietician had been involved. Care plans had not always been completed for all identified needs, for example no care plan for personal care was available for one person, although it was clear that personal care was being carried out. The need to ensure care plans are available for each identified need was discussed with the staff and the managers. Westerley unit – the service user plans were comprehensive and included all care and healthcare needs and how these are to be met. All assessments were up to date to include assessments for falls and the use of bedrails, for which written consents had also been obtained. Wound records were up to date and clearly identified each individual wound and the progress being made. Oaks unit – In one service user plan viewed some of the assessments had not been fully completed. Care plans for identified needs were in place. It was not clear if one GP instruction had been carried out in relation to infection control and this was to be investigated and addressed. The second service user plan viewed was comprehensive and up to date. Wound care documentation was up to date. Park unit – a wound dressing change had not been recorded on one occasion. Also, some inaccurate information that could place the person at risk had not been identified. The second service user plan viewed was up to date and clearly identified the persons’ needs. The Inspectors spoke with the Community Nursing Advisor who was reviewing the wound care documentation. She was positive about the improvements made by the registered nurses in relation to wound care documentation and that registered nurses represent the home at tissue viability meetings to discuss up to date good practice and guidance. There was evidence of input from other healthcare professionals and regular planned visits from the GPs. Following a POVA concern a CSCI Pharmacy Inspector carried out an inspection of Donald Sword and Garden units on 04/04/07 and a separate report is available for that inspection, which identified some shortfalls in one unit, generating 4 requirements. At this inspection the medication management for Westerley, Oaks and Park units was viewed. Medications were being well managed on these units. The home uses a monitored dosage system (mds) for medications. There were lists of specimen staff signatures for the registered nurses involved in medication administration. Receipts, administration and disposal of medications had been clearly recorded, with no gaps in recording identified. A photograph is available plus allergy information is recorded for each person. Liquid medications are dated when opened, as are any medications received in boxes rather than the mds. For people being fed via a Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 11 percutaneous endoscopic gastrostomy tube, wherever possible a liquid version of the medication to be given is obtained. Where a liquid is not available then an agreement to crush medications had been signed by the GP. On 2 units the lancets being used for blood glucose monitoring were not one of those approved for professional use. Correct lancets were available on other units and the Registered Manager promptly removed the incorrect lancets and said that this would be confirmed with the GP. It is acknowledged that the home had been using the correct lancets at previous inspections. 2 prescription creams were being stored in a persons bedroom and this was corrected at the time of inspection to ensure secure storage. It was noted that there was quite a large number of medications that had been supplied in boxes rather than the mds and it was explained that this was mainly for people quite recently admitted to the home. The Inspectors recommended that this be reviewed to ensure wherever suitable, people are having their medications supplied in the mds. Controlled drugs are appropriately stored and records were correct and up to date. Clinical room temperatures were within safe limits and fridge temperatures were generally satisfactory, with maximum temperatures being over 8° centigrade on occasion and the registered nurses said that they would ask the maintenance man to address this. Staff were seen caring for people in a gentle and professional manner, respecting their privacy and dignity. People spoken with said that staff are kind and do look after them well, and throughout the home people looked well cared for and content. On the dementia care units staff were being very patient and caring, and were aware of how to manage people exhibiting some challenging behaviour. Personal clothing is labelled and people were well dressed to show individuality. Some of the people spoken with said that their religious and cultural needs are catered for and respected. Bedrooms viewed were personalised and people can bring in personal possessions in line with fire safety. One person commented that it was like a ‘second home’ and other positive comments were received. Staff had received training in the care of the dying. Policies and procedures are in place for this, and clear records of peoples’ individual wishes for their end of life care were seen in some of the service user plans viewed. The registered nurses explained that in some instances the people did not yet wish to discuss this topic and that this was being respected. One healthcare professional spoken with said that the home had made progress in the area of palliative care and further input and training was being planned. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 12 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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision is satisfactory and information regarding individuals’ hobbies and interests is obtained, thus giving the activities co-ordinators the information to plan activities to meet individual needs. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has two activities co-ordinators and there is a programme of activities available. People are asked about their hobbies and interests and individual information and an activities diary is maintained for each person. Following a recent survey of people living at the home the activities provision is being reviewed to include more outings and also taking people out into the garden in good weather. More work is needed to continually improve the activities provision in line with individual needs and preferences, and the Managers were very aware of this and are working towards it. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made welcome at the home and representatives are kept up to date with any issues. The home has contact details for advocacy services via Age Concern and ‘First Voice’, the Ealing advocacy service. This information is being added to the Statement of Purpose and Service User Guide. One Inspector viewed the kitchen, which was clean and tidy and the kitchen records were up to date. The home uses a ‘cook chill’ system for meal provision. People spoken with said that they were satisfied with the food and that choices are offered, to include options to meet cultural and religious needs, and overall the comments made by people on the CSCI surveys were also positive about the food. Comment in particular was made about the Catering Manager, who visits the people living at the home and works hard to meet individual needs. The Inspectors sampled the lunch on both days of inspection and the meals were tasty and well presented. Information regarding peoples likes and dislikes is recorded, plus any special dietary requirements to include vegetarian, Halal, Caribbean and individual requests. Staff were available to assist people with their meals if required, and did so in a discreet and respectful manner. 24 of the people living at the home are fed via a percutaneous endoscopic gastrostomy feeding tube, and clear feeding regimes and related records were in place. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the people who live there. EVIDENCE: The home has a clear complaints procedure in place and on display in the home. In the last 12 months the home has had 38 complaints recorded. These include all concerns raised, however minor. People living at the home and visitors spoken with said that any issues raised are promptly addressed. The home has procedures in place for the management of any POVA issues, and also follows the Ealing Safeguarding Adults documentation. There have been 3 POVA issues since the last inspection and these have been correctly reported and managed. Staff had received training in POVA from the safeguarding adults manager for the Borough of Ealing, and those spoken with were clear that they would report any concerns. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is maintained to a good standard, providing people with a clean, comfortable and homely environment to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The Inspectors carried out a tour of each unit. There was evidence of ongoing redecoration and the home has a maintenance strategy for the environment with areas of refurbishment planned to include timescales for completion. The kitchen on Oaks unit has been replaced with plans for this on 3 other units. The home was clean and was being well maintained. On each unit there is a repairs book that is checked daily by the maintenance people and any issues promptly addressed. Assisted bath, shower and toilet facilities are available on each unit and all the bedrooms have en suite facilities. Equipment to meet the needs of the people living at the home was available. The home has an enclosed garden that people can sit out in during the good weather. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 16 The home was clean and smelled fresh throughout. Staff have received training in infection control, with further training planned. Comments received included ‘the home is always clean and fresh’, ‘every day they clean my bedroom’ and ‘always kept clean and tidy’. Policies and procedures are in place for infection control and protective clothing to include gloves and aprons were available. Disinfecting hand rub is kept at the reception desk and a notice to ask visitors to use this was on display. The laundry room was clean and tidy. The laundry person obviously took pride in her work and items were neatly stored and had been ironed. There are 2 washing machines with hot wash programmes for infection control and 2 tumble dryers. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were appropriate to meet the needs of the people living at the home. Training provision is good, thus providing staff with the skills and knowledge to care effectively for people living at the home. Systems are in place for the vetting and recruitment of staff, thus safeguarding people living at the home. EVIDENCE: At the time of inspection the home was being staffed to meet the needs of the people living there. A sliding scale of staffing for Oaks and Park units was on display and was based on 1 member of staff for 5 people. The need to keep the staffing under review in line with the dependencies of the people living at the home and not just the numbers of people was again discussed. The General Manager said that Westerley unit is to be closed on a temporary basis and with this closure the staff will relocate to the other general nursing units to provide a higher ratio of staff. The pre-inspection questionnaire recorded that 60 of care staff are qualified to NVQ level 2 or above in care. Staff also confirmed that they are encouraged to continue NVQ training to a higher level. 3 sets of staff employment records were viewed. These contained the information required under the Care Home Regulations 2001. The application Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 18 form is a standard one for Catalyst, the umbrella company. This form does not ask for the reason for leaving previous employment, and only asks this for the most recent or current employment prior to applying to the home. The General Manager said that this information is discussed at interview and comprehensive interview records are maintained. The General Manager said that in future the letter sent out with application forms would ask that the reason for leaving be included for all periods of employment where the applicant worked with children or vulnerable adults. The home has an induction and foundation training programme based on the Skills for Care common induction standards. Staff confirmed they do receive training in topics relevant to the care of the people living at the home, to include dementia care training. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home and does so in an open manner, thus supporting the staff, people living in the home and visitors. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Monies held on behalf of people living at the home are being well managed and securely stored, thus safeguarding them. Overall the systems for the management of health & safety throughout the home are good, thus safeguarding people living at the home, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse who has completed the Registered Managers Award. She has also completed the Assessors Training to Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 20 be an internal assessor for carers undertaking NVQ in care training. The Registered Manager said that this training has helped her to understand the expectation of the level of attainment for NVQ levels 2 & 3 in care. She has also undertaken training in topics relevant to her management role to include appraisals, disciplinary processes and leadership training. The home also has a General Manager who is responsible for the management of the business side along with the finances and overall strategy for the home. Both managers have an open approach and the home is being effectively managed. The home has a system in place for quality assurance. A recent satisfaction survey had been carried out and an action plan to address any issues identified had already been put in place and areas actioned. There are regular meetings for each unit, Heads of Departments, registered nurses and carers meetings. The Registered Manager reported that they had started visitors meetings however these were poorly attended and it had been found that individual meetings were more appropriate and these are held. The home also produces a monthly newsletter which is informative and copies of which are available in the reception area and on each unit. There are individual appraisals and annual objectives are set for each Head of Department. Monthly audits of areas of care are carried out. There is 3 monthly performance monitoring completed and this is very comprehensive covering all aspects of the home. One Inspector viewed the records for monies held on behalf of people living at the home. All records are clear and receipts are available for all expenditure. Where monies are not held by the home, invoices are sent to the representative for the person. Three money wallets were checked against the records and these were accurate and up to date. Where monies are held on behalf of people being funded by Social Services or the Primary Care Trust, meetings are held to discuss this aspect of each persons finances. Health & safety training had been recorded and this was up to date with the exception of moving & handling updates, which needs to be addressed. Thorough risk assessments had been carried out for all areas of the home, equipment in use and safe working practices. Clear accident records were seen and all accidents are investigated and action taken to minimise the risk of reoccurrence. Maintenance and servicing records were sampled and those viewed were up to date. The pre-inspection questionnaire recorded that all areas of servicing were up to date. A weekly facilities and housekeeping schedule is maintained. Fire drill records did not list the attendees and the managers said that this could be easily addressed by copying the staff signing in records for the relevant days and keeping this with the fire log records. The fire risk assessment had been carried out last in September 2006 with a few minor shortfalls identified, and these had been promptly addressed. There is a maintenance strategy for the environment with timescales for completion. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17 Requirement Care plans must be formulated for all identified needs. Information must be complete and up to date. Timescale of 06/10/06 not met. Assessments must be completed accurately and in full, so that a clear picture of the individuals’ condition is obtained. Where weight loss is identified the documentation must show what action has been taken to follow this up, in order to evidence that the issue has been addressed. There must be evidence that all staff have undertaken moving & handling updates in line with current legislation in order to ensure the safety of the people living at the home. Timescale for action 01/06/07 2. OP8 17 01/07/07 3. OP8 17 01/06/07 4. OP38 18 01/07/07 Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations It is strongly recommended that the boxed medication be reviewed and wherever possible this be supplied in the mds. Where a maximum temperature for the medications fridge is over 8° centigrade, action should be promptly taken to address this. Acton Care Centre DS0000034968.V336574.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Acton Care Centre DS0000034968.V336574.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. 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