Inspection on 16/08/06 for Half Acre House

This inspection was carried out on 16th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Half Acre House 18/01/06

Half Acre House 26/05/05

Half Acre House 15/09/04

Half Acre House 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Half Acre House Higher Ainsworth Road Radcliffe Manchester M26 4JH Lead Inspector Stuart Horrocks Key Unannounced Inspection 09:30 16th August 2006 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 Half Acre House DS0000008404.V295278.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. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Half Acre House Address Higher Ainsworth Road Radcliffe Manchester M26 4JH 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) 0161 725 9876 0161 724 8642 halfacre@highfield-care.com Southern Cross Care Homes Limited Miss Sarah Elizabeth Ashton Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users to include: up to 32 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 18th January 2006 Date of last inspection Brief Description of the Service: Half Acre is a care home providing personal care only and accommodation for up to 32 older people. The home is owned by Southern Cross Healthcare. Half Acre is located approximately 1 mile from the centre of Radcliffe and 3 miles from Bury. It is on a bus route and has a number of shops and a pub nearby. The premises are purpose built on three floors with a passenger lift. Accommodation is provided in single rooms with en-suite facilities, with three former double rooms available to share should service users require this. There is a large lounge/dining room on the ground floor and there are smaller lounges on the upper floors. There is a garden and patio area and car parking to two sides of the building. A Service User Guide that describes the home’s services is available in the home and the provider gives other information about the home to new and prospective residents and their families verbally. A copy of the latest inspection report is also displayed in the home. As of August 2006 the weekly charge for accommodation and services is between £339:00 and £432:64 with an additional charge being made for hairdressing and chiropody services. Half Acre House DS0000008404.V295278.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 key inspection, which included a site visit that was started at 7:00am on the 16th August 2006. It took place over one day and it lasted for about eight and a half hours. The time was split between talking to the Manager and checking records, looking around the home, watching what was happening and talking to residents and other staff. Three residents and three staff were spoken with. A completed pre-inspection questionnaire was received along with feedback surveys from GP’s. Of the surveys sent out two were returned by the GP’s. The care services (case tracking) provided to three specific residents were used a basis for the process of the inspection. What the service does well: What has improved since the last inspection? Some progress has been made by the manager and the staff to make sure that the things, which needed improving from the last inspection, have been done. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 6 Towels that were in a poor condition have been replaced, advice about Legionella risk has been obtained and staff recruitment information has been improved. 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. Half Acre House DS0000008404.V295278.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 Half Acre House DS0000008404.V295278.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): 3. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Pre-admission visits, and the initial assessment process, enable all parties, including potential residents and their relatives, to reach a decision as to whether the home will be able to meet their needs. The home does not provide intermediate (rehabilitative) care so this Standard (6) does not apply. EVIDENCE: The care files of two recently admitted residents were checked for the required pre-admission needs assessment information. Both of these contained local Social Services needs assessments and also satisfactory and detailed in-house needs assessments. The inspector was informed that all new residents routinely have an in-house pre-admission needs assessment done no matter who is paying for their care. These were seen in the above checked files. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 9 The manager said that new residents and their families are welcome to visit the home where they can spend some time, meet the residents and the staff, and have a meal before deciding to live there. This visiting opportunity is described in the useful and informative Service User Guide (Residents Information Guide) and was also confirmed in discussion with residents’ and staff. Half Acre House DS0000008404.V295278.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. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Proper arrangements are in place that ensures the residents health care needs are monitored and met. Individual care plans are also in place, which were up to date, regularly reviewed and provided the staff with the information needed to give a good standard of care. The home’s medication systems are satisfactory in ensuring that residents received medication as prescribed and care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. EVIDENCE: The care files of the three case tracked residents were looked at. These contained care plans that had been kept up to date monthly as is required. The care plans are well laid out and they are easy to read and follow. Each plan contained details of health, personal and social care needs for the resident. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 11 The staff said that they knew each residents needs by reading the care plans, which are readily available to them. Talking to residents, the manager and the staff and looking at records showed that the resident’s health care needs are taken care of and that when necessary health workers such as doctors, nurses and opticians are called. A number of risk assessments are in place; all of these had been reviewed regularly with the information being up to date. Records also showed that the weight of the residents’ is also regularly checked. Information received before the inspection indicated that some of the staff were uncomfortable about the way that a resident with a potentially infectious condition was being cared for in that they didn’t think that adequate precautions were being taken to protect others. Discussion with the manager and the checking of records showed that the home was dealing with this condition properly and that advice had been sought from professional workers, written guidance obtained and that the home’s policies and procedures were being properly followed in order to both eradicate the condition and to protect other residents and the staff. The medications are securely stored in a locked and tethered medication trolley.A locked room is also available that has a Controlled Drugs cupboard, another lockable medicine cupboard and a medicine ‘fridge. The residents’ medicines are provided in pre-filled blister packs with preprinted prescription/recording sheets also provided. These records were found to be properly completed and to be up to date. The medications supplied are checked in to the home , and medicines returned to the pharmacy are also recorded. Identification photographs of each resident are kept with the medication administration records. Those staff that give out medicines have been given the necessary training for this task. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines and the use of homely remedies. No resident was dealing with their own medicines at the time of the inspection. Records looked at emphasised the need for the residents privacy and dignity to be respected at all times, and the staff gave examples of how the residents privacy and dignity were promoted in the home, such as when giving personal care. Residents said that the staff treat them with respect and that their dignity is valued, for example they said that the staff knocked on their bedroom doors Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 12 before entering. Those residents spoken with said that the staff were “respectful”, “considerate”, “pleasant” and that “they (the staff) talk to us properly”. The staff were seen to have a good relationship with the residents, speaking to them in a natural, caring and friendly manner. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 adequate. This judgement has been made using the available evidence including a visit to this service. Presently the home does not offer enough sufficient social, cultural and recreational activities to keep the residents interested and stimulated. Visiting arrangements are flexible, but the home needs to make sure that the residents are made aware of choices from the food menu. EVIDENCE: The residents said that they have choice about their daily routines thus they are able to spend their time as they wish. Information received before the inspection alleged that residents are made to rise from 6:00am, that 15 residents have to be up by 8:00am and that residents are being taken to bed by 7:00pm and that all of the residents are in bed by 9:00pm. In response to this allegation the inspector arrived at the home at 7:00am on the day of this inspection. At this time seven residents were up, in discussion all of these people appeared to be up at this time of their own choice. By 8:30am 11 residents were up and sat in the lounge/dining room waiting to be served with their breakfast. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 14 In discussion the manager and the day and night care staff vigorously denied that there were any instructions about when residents should rise or retire and they said the residents are free to choose when they get up from and go to bed. The inspector spoke to a number of residents about this subject; they all said that they themselves decided when to rise and retire with some saying that they did get up and go to bed early but that they were simply following lifelong routines. In essence this allegation was not substantiated. Further information received before the inspection alleged that a resident who shouts out a lot disturbs the other residents and is therefore often left in their bedroom. The caller felt that this was unfair and that the resident was being unnecessarily isolated. The inspector observed this resident during the period of the inspection, this person did shout out at times but was easily distracted from this and did spend all of the day in the lounge. The manager was well aware of this problem with the resident having been diagnosed with a particular problem with treatment prescribed. The manager did say that at times the resident did spend some time in their bedroom where they became calmer. The residents family are aware of the difficulties surrounding their relative. The inspector and the manager discussed the care needs of this resident and the inspector suggested that a decision may have to be made as to whether the home will be able to continue to meet this particular residents needs. The issue of residents being able to make choices is described in the home’s Statement of Purpose and also the Service User Guide. Discussion with the residents showed that they made choices about when to rise and retire, about the food they ate, where they spent the day and spent their time and the clothing they wore etc. The staff described how they assisted residents with choices such as choosing clothing and food etc. The staff were seen to treat residents in a dignified, respectful and curteous manner and to deal with them in a friendly and caring way. At the time of previous inspections the home employed an activities worker who devised and ran a programme of social and recreational activities for the residents, but this post is currently vacant. A programme of leisure activities is available at the home, but the inspector’s enquiries revealed that relatively few activities were being provided. Discussion with the staff showed that they do provide the residents with some recreational activities when and if they have the time to spare from their caring duties. Leisure activities are therefore not happening regularly and the displayed programme is also not followed. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 15 Paperwork is also available that records when residents have taken part in activities but the use of this has recently lapsed. However the inspector was told that a new activities worker is due to start work at the home on Monday the 21st August 2006 when it is expected that regular activities will re-start. Whist allowing for the above the registered person must make sure that the residents are regularly provided with stimulating, meaningful and fulfilling social and recreational activities From talking with residents and staff the inspector confirmed that the visiting arrangements are flexible with these being described in the resident’s information guide. Those residents spoken with said that they “were free to see their visitors wherever they wanted to”. They described taking visitors to their bedrooms for privacy or seeing them in the main lounge. The residents said that visitors are made welcome and they said that their visitors are offered refreshments. The home has a four weekly menu that offers a variety of good nourishing food. The menu is of single choice with alternatives being available, however those residents that the inspector spoke to were not aware that such alternatives were available. The home must make sure that the residents are made aware of alternative food choices and the inspector suggests that this information is included on the menu sheets. The inspector saw that the midday meal was well presented and looked appetising. The residents said that the food “good”, “appetising”, that “you get enough to eat”. The residents also said that drinks and snacks were available at most times of the day. The dining area is very compact and at times staff members have difficulty manoeuvring wheelchair users in and out of the places available. There are only 22 dining places downstairs for a potential 29 service users. When the home is fully occupied, this area is overcrowded and cannot accommodate all service users necessary furniture, equipment, visitors and activities taking place. Previously the company agreed that this was the case and the planning department, in February 2004, passed the plans for a new conservatory to be built. This work is yet to be undertaken with the requirement made at the time of the last inspection regarding this work being therefore repeated. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using the available evidence including a visit to this service. Although a clear complaints procedures is available within the home the residents need to be made more aware of how to make a complaint so that they are confident that their concerns will be listened to. EVIDENCE: The home has a satisfactory complaints procedure that states how a complaint is to be made, who to and that an initial response will be provided within seven days with a final outcome forwarded within 28 days. The facility of making concerns known directly to the CSCI is also included in this paperwork. The complaints procedure described above is included in the Service User Guide, a copy of which was available in the home’s entrance area as was a copy of the complaints procedure. Discussion with residents showed that they were not aware of the home’s complaints process and some said that they would be hesitant in making their concerns known to the staff or the manager. The home must make sure the residents are made fully aware of the home’s complaints procedure, that they have the right to raise concerns and that such expressions of concern would be welcomed. It was clear in discussion with staff that they knew what steps to take should a resident make a complaint. A number of staff said that if “they couldn’t sort things out at the time” then they would inform the manager about the problem. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 17 The home has a proper record for writing down complaints. No complaints have been made to the home since the last inspection in January 2006, however a number of concerns have been made directly to the CSCI the details of which have been dealt with in various parts of this report. There are written procedures and policies covering adult protection, whistle blowing, the none acceptance of gifts, borrowing money and legacies and the home has a full copy of the Bury inter-agency adult protection policy and procedure. Looking at records showed that the staff had been given training in adult protection procedures. In discussion the staff confirmed that they had received such training and they were aware of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 18 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 & 26. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Half Acre care home provides clean, safe, comfortable, homely and friendly surroundings for the people living there. However there are concerns about the adequacy of communal space to the ground floor and kitchen hygiene needs to be improved. EVIDENCE: Half Acre is well maintained both to the inside and to the outside. Redecoration and replacement of furniture and equipment etc is done on a continuous basis. New carpets have recently been fitted to the corridors and to the ground floor lounge dining room. The three case tracked resident’s bedrooms and others were checked. All were found to be properly decorated, furnished and equipped and those residents spoken with were satisfied with the standard of the accommodation provided. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 19 The home has a properly equipped laundry and information regarding the control of infection is available. Residents clothing is marked to enable easy identification and the residents had no complaints about the laundry service provided by the home. As mentioned previously in this report a requirement was made at the time of the previous inspection that “the registered provider takes the necessary action to increase communal space to the ground floor including consideration to improve storage of equipment such as wheelchairs, hoists etc” This work has yet to be addressed, details must be forwarded to the CSCI as to what action is to be taken to address this issue. A further requirement made at the time of the last inspection was that “the registered provider addresses the issues relating to the ground floor bathroom”. This bath is unassisted and none of the residents living at the home are able to use this bath with this having been the case for some considerable time. The inspector requires that consideration be given to either providing an assisted bath in this room or to converting the facility to a shower room. Another requirement made previously was that “the local environmental health department is contacted to ensure that all appropriate action has been taken in respect of Legionella”. This requirement has been addressed with the above department being satisfied that the necessary steps have been taken to control Legionella risk. Information received before the inspection was that the nurse call system on the first and second floors of the home does not sound on the ground floor and that therefore residents accommodated on these floors are unable to summon assistance from the staff. This was the position at the time of this visit. The home manager has risk assessed this situation and the staff have been instructed to check the alarm repeater panel on the ground floor regularly where, although the “buzzer” does not sound the display does show when and where a call has been made .The manager told the inspector that the system is due to be repaired on the 24th August 2006. Other information received before the inspection was that the kitchen was unclean. Examination of this area during the inspection showed that cleanliness needs to be improved and a requirement is made in this report to this effect. Whilst looking at the kitchen the inspector noted that the dishwasher was broken and unable to be used. The manager told the inspector that the company has agreed to the repair or replacement of this item but that the funding has yet to be released. A requirement is therefore made that this work be actioned.. The remainder of the home was clean and tidy throughout and was free from any offensive odours therefore providing a pleasant place to live. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 20 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 the available evidence including a visit to this service. Staff recruitment and training is satisfactory but staffing levels need to be reviewed therefore ensuring that the assessed needs of the residents can be met. EVIDENCE: Looking at staff rotas showed that as well as employing care staff, the home also employs domestic, catering and maintenance staff. The manager and the staff described a largely stable staff group some of whom have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. The inspector checked a number of staffing rotas, these showed that apart from the manager three care workers were available throughout the day and three staff available overnight. Information received before the inspection indicated that there was insufficient staff to fully meet the residents care needs and that at times some staff were working overlong hours. In discussion the staff said that they felt that the above staffing levels were not always sufficient to be able to care for the residents properly, that they were only just able to meet the residents needs and that at times that they did work Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 21 for many days before getting any time off with the result that they did become tired. The manager did accept that occasionally some staff had worked excessive hours, but she pointed out that the staff had volunteered to do additional shifts and that the company would allow the use of agency staff when necessary. Those residents spoken with also said that at times that they had to wait before staff were able to deal with their requests for assistance. In view of the comments made by both the residents and the staff the inspector requires that daytime staffing levels be reviewed to ensure that the assessed needs of the residents can be met. The residents said that the staff are “kind”, “happy to help” and that they were “patient and considerate”. The home presently accommodates 23 white British residents, 16 of these are female and seven are male. The staff group is made up of 13 females and one male , including one overseas worker. The makeup of this staff group does not appear to cause any difficulties. There is a good age and experience mix of staff. Of the 14 care staff employed at the home six have got a National Vocational Qualification in Care at either Level 2 or 3. A further five staff are also presently undertaking this training. These figures almost meet the requirement for the home to have 50 of the care staff with completed NVQ level 2 qualifications or above by the end of 2005. The files of two recently employed staff were checked for safe and proper recruitment. These showed that these people had been correctly recruited, that the necessary checks had been completed and that a previous requirement regarding past employment history had been dealt with. Looking at staff training records and talking to the staff showed that they had been given training in subjects such as safe moving and handling, health and safety, food hygiene, fire safety and first aid and induction to the job training. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 22 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 & 38. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The manager of the home provides leadership and support for the staff to ensure that the residents receive a satisfactory standard of care and the home consults the residents and their families about the way that the service is run so that both improvements can be made and problems can be dealt with. EVIDENCE: The home manager has been previously approved and registered with the CSCI and she has been running the home for approximately the last four years. The registered manager has successfully completed the Registered Managers Award but has not yet received certification of this award. A requirement made at the last inspection regarding this certification remains outstanding. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 23 The staff said that the manager runs the home in an open and inclusive way and that she is fair-minded, approachable and easy to get along with. A requirement of Standard 33 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. In January 2006 the home sought the views of both residents and their families by the use of survey questionnaires. The manager told the inspector that the home was in the process of repeating such a survey at the time of this inspection. The home holds money for a number of residents for safekeeping. This system was checked with the details found to be properly recorded. The money is held in a “pooled” account with the total balance checked and recorded at weekly intervals. Secure storage is available for the safekeeping of money and of any valuable items. Looking at records and maintenance certificates showed that these were up to date and the examination of paperwork and conversations with staff also confirmed that they had been provided with the necessary training so that they can work safely. The home is safely maintained with fire precautions tests done regularly and the details of accidents are properly recorded. Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 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 3 Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 25 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 OP12 Regulation 16 Timescale for action The registered person must 11/09/06 ensure that the residents are regularly provided with stimulating, meaningful and fulfilling social and recreational activities The registered person must 11/09/06 ensure that the residents are made aware of alternative food choices to the main course described on the home’s menu. The registered person must 11/09/06 ensure that the residents are made fully aware of the home’s complaints procedure and that they have the right to raise concerns and that such expressions of concern would be welcomed. The registered person must 18/09/06 ensure that the CSCI is informed as to what action is to be taken to increase communal space to the ground floor. (Previous timescale of 30/04/06 not met) The registered person must 18/09/06 Version 5.2 Page 26 Requirement 2 OP15 16 3 OP16 22 4 OP20 23 5 OP21 23 Half Acre House DS0000008404.V295278.R01.S.doc 6 OP22 23 ensure that the CSCI is informed as to what action is to be taken to address the issues relating to the ground floor bathroom (Previous timescale of 30/04/06 not met) The registered person must 24/08/06 ensure that the defective nurse call system is repaired The registered person must 18/09/06 ensure that the defective dishwasher in the home’s kitchen be repaired. The registered person must 11/09/06 ensure that kitchen hygiene standards are improved. The registered person must 11/09/06 ensure that daytime staffing levels be reviewed therefore ensuring that the assessed needs of the residents can be met at all times The registered person must 18/09/06 ensure that the issues surrounding the Registered Managers Award certificate are resolved. (Previous timescale of 31/01/06 not met) 7 OP22 16 8 9 OP26 OP27 22 18 10 OP31 8 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Half Acre House DS0000008404.V295278.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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