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Inspection on 18/09/06 for Acton Care Centre

Also see our care home review for Acton Care Centre for more information

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is being effectively managed. Pre-admission assessment processes are thorough. Staff care for service users in a courteous and sensitive manner. There was evidence of good team working on the units. Service users are well cared for, to include end of life care. The food provision in the home is good and choices are offered. The home has an open visiting policy and visiting is encouraged. Complaints are well managed and service users and visitors commented that any concerns are promptly dealt with. Procedures for safeguarding adults are robust and any concerns are promptly reported. The home is well maintained and there is a good system for redecoration and refurbishment in place. Systems are in place for effective infection control. Staff receive training in health & safety topics and there is ongoing NVQ in care training taking place. Systems for quality assurance are in place and evidence that satisfaction surveys are undertaken. Service users personal monies are being well managed. Good systems are in place for the management of health and safety throughout the home.

What has improved since the last inspection?

There had been an improvement in the completion of wound care documentation. The systems in place for the recording of controlled drugs were being followed. Staff are now receiving regular supervision. The home had 10 requirements overall at the last inspection.

What the care home could do better:

Shortfalls were identified in the formulation of service user plans, to include some identified needs not being planned for, risk assessments for falls, bedrail risk assessments and consents. Shortfalls in the management of medications were identified and must be addressed by the Registered Manager. There isstill an issue with the lack of storage facilities in the home, which the General Manager is continuing to work on. Staffing levels need to be reviewed in line with service users dependencies to ensure that the needs of service users are being met at all times. Repeated shortfalls in vetting and recruitment procedures are of concern and this needs to be addressed promptly and robustly.

CARE HOMES FOR OLDER PEOPLE Acton Care Centre 48 Gunnersbury Lane Acton London W3 8EF Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 10:20 18 & 19 September 2006 th 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 Acton Care Centre DS0000034968.V312429.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.V312429.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.V312429.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. Two named service user 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. 15th December 2005 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 £766, dependent on the assessed needs. Acton Care Centre DS0000034968.V312429.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 30 hours was spent on the inspection process. A tour of each unit was carried out, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 17 service users, 7 visitors, 20 staff and 3 healthcare professionals were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, has also been used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls were identified in the formulation of service user plans, to include some identified needs not being planned for, risk assessments for falls, bedrail risk assessments and consents. Shortfalls in the management of medications were identified and must be addressed by the Registered Manager. There is Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 6 still an issue with the lack of storage facilities in the home, which the General Manager is continuing to work on. Staffing levels need to be reviewed in line with service users dependencies to ensure that the needs of service users are being met at all times. Repeated shortfalls in vetting and recruitment procedures are of concern and this needs to be addressed promptly and robustly. 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. Acton Care Centre DS0000034968.V312429.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.V312429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives are provided with the information they need to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff had not all received training in dementia care, thus they did not all have the specialist knowledge to care for service users fully with such a diagnosis. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Both documents are up to date. Copies are available in each service users room. There is a written contract/agreement with the Primary Care Trust and local Social Services for service users being funded by these departments. Contracts were available for service users funded privately. There is a clear audit trail for this documentation from the time of the pre-admission assessment. Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 9 The home has a pre-admission assessment that is carried out for all routine admissions to the home. These were seen in some of the service user plan documentation viewed and were comprehensive, giving a clear picture of the service user and their needs. Copies of Social Services and Primary Care Trust assessments, plus hospital discharge information were also available. For one service user admitted to the home as an emergency, no assessment had been carried out since the admission. This was discussed with the Registered Manager. Staff had received training in palliative care. Training & updates are required in dementia care, to ensure all staff caring for service users with dementia have the skills and knowledge to do so effectively. A sensory room was being planned for the dementia care unit, which will benefit the service users. Acton Care Centre DS0000034968.V312429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were up to date, however shortfalls in completion could place service users at risk of their needs not being fully met. Shortfalls in risk assessment documentation could potentially place service users at risk. Medications are being well managed at the home, however some shortfalls need addressing to fully safeguard service users. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Two service user plans were viewed on each unit. Oaks unit. For one service user quite recently admitted to the home only one care plan had been completed. No pre-admission assessment was available, and action had not been taken to complete the relevant documentation promptly following admission. This was a major shortfall and was discussed with the General Manager and Registered Manager, and action was taken to address the situation, with the service user plan being 50 completed by the second day of inspection. The other service user plan viewed on this unit was Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 11 generally up to date. Some care plans for identified needs had not been fully completed. Park unit. Most of the information was up to date. Risk assessments for the use of bedrails were in place, however the consent to use of bedrails was not signed for one service user. In one of the service user plans viewed some of the information had not been fully completed and this was addressed by the second day of inspection. Westerly unit. These were comprehensive and up to date. For one service user whose condition had changed and for whom bedrails were now in use an assessment and consent required completing. Donald Sword unit. Generally these were clear and up to date. One bedrail consent form was not signed. For one service user the nutritional assessment had deemed the service user to be at high risk, however no care plan had been formulated to reflect this. This had been completed by the second day of inspection. Wound care documentation was comprehensive and a separate care plan and wound treatment plan was available for each wound identified. Two service user plans were viewed on Garden unit. These were comprehensive and up to date, and gave a clear picture of the service users needs and how these are to be met. There was evidence of monthly reviews of service user plans taking place on all units. Correction fluid had been used on two service user plans viewed. Risk assessments for falls had been formulated, but in some instances the information was incomplete. Input from the GP and other healthcare professionals is recorded in the service user plans. The Inspectors met with the GP who visits the home three times per week. He said that staff are helpful and well organised for his visits. The CSCI Pharmacist Inspector carried out an inspection on 19/09/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were observed interacting with service users in a professional and caring manner. Staff knock on doors prior to entering service users bedrooms. Where service users require assistance with their meals this was done discreetly and sensitively. Service users and visitors spoken with said that the care provision in the home is a very good standard, and staff are approachable and helpful. Service users individual items of clothing are labelled. Service users can bring in personal possessions, subject to fire safety. The wishes of the service users and their representatives in respect of death and dying are recorded in the service user plan. Policies for death & dying are in place. Several staff members have received training in the care of the dying, and were seen caring for service users in a gentle and sensitive manner. Visitors can stay with their loved ones, and comfortable seating and refreshments are available. Acton Care Centre DS0000034968.V312429.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 at least once during a 12 month period. 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. There are activities provided for service users with a programme in place, however some clarification is needed for specialist provision for service users. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home employs two activities co-ordinators. The home has in place an activities programme, which is advertised in the monthly newsletter and in each unit. The Registered Manager stated that staff had received training in activity provision since the last inspection. The Inspectors were not clear as to how the activities programme is formulated to ensure that service users individual and specialist interests are catered for. A separate file for recording service users individual involvement in activities is maintained on each unit. Some service users choose not to participate in any activities, and others are unable to due to their disabilities. The home also has a Chaplaincy service, and at the time of inspection a representative from the Catholic Church visited some service users to give them holy communion. Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy, and details of this are available in the Statement of Purpose and Service User Guide. On both days of the inspection visitors were present and those spoken with said that they are made very welcome at the home. Service users can choose to receive their visitors in their own rooms, in one of the day rooms or in the garden, depending on their own wishes. There is a visitors notice board detailing the complaints procedure, monthly newsletter and the activities programme. Details of Advocacy Services available in the local area are freely available in the main entrance of the home. This includes details for contacting Help the Aged and Age Concern. Since the last inspection a new Catering Manager has been employed. A review of the menus has taken place in line with service users preferences. Menus are displayed in the dining areas with details of the choices available, to include specialist diet information. Service users choices are recorded. One Inspector viewed the two lunchtime meals, and service users were interacting well and enjoying their food. Service users spoken with expressed satisfaction with the food provision and confirmed that they are offered choices. The Catering Manager visits all new service users in order to discuss their diet, their likes and dislikes and to ensure the home is able to meet their needs. The kitchen was clean and tidy and all records viewed were up to date. Meals are well presented and drinks and snacks are available throughout the 24 hour period. A cooked breakfast is available, and the mealtimes have been reviewed to ensure a suitable gap between meals. Dining tables are attractively presented, with linen table clothes and napkins, plus table decorations. Each unit has a kitchenette where essential supplies are available. Acton Care Centre DS0000034968.V312429.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 inspected at least once during a 12 month period. 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 clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure, and this is on display in each unit, and is also in the Statement of Purpose and Service User Guide. Since the last inspection there have been 20 complaints. The complaints documentation was well recorded with details of the investigation undertaken and an action plan for any shortfalls identified. The Registered Manager stated that she has an open door policy whereby she encourages service users and their representatives to raise any concerns so they can be promptly addressed. Since the last inspection 2 POVA cases have been identified, and appropriate action has been taken by the home in respect of these. Staff had recently received training in Whistle Blowing procedures, and those spoken with were very clear about this and said they would report any concerns. Acton Care Centre DS0000034968.V312429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was purpose built and is well maintained, thus providing a clean and homely environment for service users to live in. Communal rooms are available on each unit, providing the service users with a choice of venue. Equipment in the home is available to meet the service users needs, thus providing for the service users needs. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: A tour of the home was carried out. There is a redecoration and refurbishment plan, and areas were in the process of being redecorated. Where carpets had been damaged they had been replaced. All the bedrooms have en suite facilities. There are assisted bathing and shower facilities on each unit, plus toilet facilities situated near the communal rooms. Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 16 There are rails in the corridors and also in the bath, shower and toilet facilities as required. The home has two passenger lifts and suitable moving and handling equipment was available on each unit. Any repairs are reported and promptly addressed. Seat cushions were seen in one bathroom, and some areas are still being used for storage. There is a call bell system throughout the home. The dementia units are secure with a keypad system in place. All bedrooms are single and those viewed had been personalised. All the beds are adjustable and the rooms are appropriately furnished. There is a lockable space in each room. Service users can have a key to their room if they are able to manage, and assessments are in place for this. The temperature in the home was satisfactory. Emergency lighting is in place and records evidenced that this is regularly checked and serviced. There is under floor heating in place throughout the home. Hot water temperatures are checked and recorded. Legionella testing was up to date. The home was clean and tidy throughout. Laundry. Protective clothing to include gloves and aprons were seen on each unit. Acton Care Centre DS0000034968.V312429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was adequately staffed, although a review of service users dependencies is required to ensure staff are employed in such numbers as are necessary to meet the needs of the service users at all times. Staff had received training to enable them to meet the general care needs of service users. Recruitment checks had not all been carried out thus service users are potentially put at risk. EVIDENCE: A duty roster was available for each unit. This detailed the number of nursing and care staff on duty and where additional staffing is required. On the second day of the inspection Park Unit was short of one carer but action had been taken to try and cover this shortfall. The Inspectors noted that several of the service users have very high dependency needs, and the need to review staffing levels in line with service users dependencies was discussed with the Registered Manager. Agency staff are used by the home in order to cover shortages. One Inspector spoke with an Agency carer, who confirmed that they had been shown around the unit to include fire exits, and were working with an experienced carer throughout the shift. The home is clean and fresh, and each unit has their designated domestic staff. The housekeeping manager explained that there are currently some vacant shifts, and work is being done to recruit more domestic staff. Staffing levels in the kitchen, laundry, maintenance and administration departments were satisfactory. Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 18 More than 50 of care staff are trained to NVQ level 2 or hold and equivalent qualification. An additional 10 staff are due to complete their NVQ level 2 in December 2006. Several of the registered nurses and the Registered Manager are currently undertaking the NVQ assessor qualification. Two registered nurses are also undertaking the Registered Managers Award. Plans are also in place for the home to train 2 nurses in Tissue Viability. A sample of staff records were viewed. In both cases evidence of a current Criminal Records Bureau check for their employment by Acton Care Centre were not available. Photocopies of the Criminal Records Bureau check obtained at their previous place of work were seen in the files, but these checks have not been portable since July 2004. Shortfalls in recruitment checks had been identified at the last 2 inspections, and it is of concern that robust action has not been taken to address this. The home has in place a new training programme incorporating the core induction standards as recognised by Skills for Care. This was comprehensive and was being completed by new care staff. Training records were available. Staff spoken with confirmed that they had been receiving training. Specialist training in topics to include skin & wound care, anaphylaxis, therapeutic activity training and other relevant subjects had been undertaken. Acton Care Centre DS0000034968.V312429.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 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. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Service users monies are well managed and securely stored. Staff receive supervision, thus promoting communication and review of practice. Systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a Batchelor of Science degree in nursing. She has also completed the Registered Managers Award, equivalent to NVQ level 4 in management. There was evidence that she had been undertaking periodic training in topics relevant to the needs of the service users. Staff who spoke with the Inspectors said that the Registered Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 20 Manager is supportive and listens to any points raised. She also visits each unit at least twice a day to have an up to date knowledge of what is going on with each unit. The home also has a General Manager in post who deals with the non-clinical management aspects of the home. Regulation 26 visits take place and comprehensive reports are forwarded to CSCI. A monthly newsletter is published and available for all service users, representatives and visitors. One Inspector noted that the annual feedback questionnaires were due to take place in November 2006. It was agreed with the Registered Manager that the results would be collated and forwarded to CSCI. Audits for service user plans, medications, wound care, personal care, equipment and the environment are carried out monthly. It was noted that for some of the service user plans, where the audit had identified shortfalls, there was not a clear system for ensuring action is taken to address these. This had already been identified by the Registered Manager and she is looking at alternative recording to address this. Small amounts of personal monies are managed by the home. Clear records of income and expenditure with receipts are maintained. The Registered Provider carries out an internal and an external finance audit every 6 months. The home also has in place a ‘residents account’ and this is only used for service users for whom there is no next of kin to deal directly with personal monies. Clear records had been maintained for this account. Since the last inspection action has been taken to ensure all staff providing care receive supervision every 2 months. The Registered Manager meets with the registered nurses to identify specific aspects of care provision to be covered during these supervision sessions, to keep staff up to date with best practice. Servicing and maintenance records were viewed at random and those viewed were up to date. Fire drills for all staff had been taking place at the required intervals. On the first day of the inspection the fire risk assessment was being reviewed by a professional fire assessor. The London Fire and Emergency Planning Authority had visited the home recently and had been satisfied with their findings. Training records viewed confirmed that staff had received health & safety training to include fire safety, moving & handling and food hygiene. Other training included First Aid, infection control, and care of substances hazardous to health. Risk assessments for safe working practices and equipment are in place. 6 staff are due to attend moving & handling trainers training in November 2006. The Facilities and Services Manager has identified individual staff training needs and made appropriate arrangements to meet these. Accident records were up to date and clearly recorded, plus any trends in the falls pattern are identified and action taken to minimise re-occurrence. There are good systems in place for the management of health & safety within the home. Acton Care Centre DS0000034968.V312429.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 3 3 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 2 X 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Acton Care Centre DS0000034968.V312429.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 OP4 Regulation 18 Requirement All staff working on the dementia care units must undertake dementia care training. Updates must also take place to keep staff up to date with best practice. An action plan to address this must be drawn up. Service user plans must be formulated for all service users admitted to the home. This must be done as soon as practicable following admission. Risk assessments for falls must be fully completed. Care plans must be formulated for all identified needs. Information must be complete and up to date. Bedrail risk assessments and written consent to their use must be in place for all service users for whom they are in use. Correction fluid must never be used on legal documents to include service user plans. Medicines must be accurately recorded when administered. If medicines are not administered the correct endorsement must be DS0000034968.V312429.R01.S.doc Timescale for action 01/11/06 2. OP7 17(1)(a) 06/10/06 3. 4. OP7 OP7 13(4) 17 06/10/06 06/10/06 5. OP8 13(7) 06/10/06 6. 7. OP8 OP9 17 13(2) 19/09/06 01/10/06 Acton Care Centre Version 5.2 Page 23 8. 9. 10. OP9 OP9 OP9 13(2) 13(2) 13(2) 11. OP9 13(2) 12. 13. 14. OP9 OP22 OP27 13(2) 23(2)(l) 18 15. OP29 19 used. The homes administration policy must be adhered to. (previous timescale of 01/01/06 not met) Accurate recording of all receipts of medication must be maintained. Continuous supplies of medication must be maintained. Controlled Drugs must be stored in a cupboard meeting the requirements of the Misuse of Drugs Act. More attention must be given by nursing staff to the monitoring and recording of pain to allow review of medication. Records of the current INR/warfarin dosage must be kept accessible. Bathrooms must not be used as storage areas. Staffing must be reviewed in line with service users dependency levels to ensure the home is appropriately staffed to meet the service users needs at all times. All records required under Schedule 2 of the Care Homes Regulations 2001 must be in place. Staff must not be employed until all required checks have been completed. (previous timescales of 01/07/05 and 13/01/06 not met) 01/10/06 01/10/06 01/10/06 14/10/06 14/10/06 06/10/06 01/11/06 19/09/06 Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 24 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 That storage of medication in Park unit is reviewed Room Temperature and fridge charts must be regularly reviewed to ensure the correct storage of medication. If the temperature of the clinical rooms regularly exceeds 25 degrees then air conditioning should be considered. It is strongly recommended that the activities programme be reviewed to ensure it identifies activities for service users with specialist needs such as dementia. 3. OP12 Acton Care Centre DS0000034968.V312429.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. 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