Care Home: Acacia Court

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What the care home does well The home is well managed and the staff team are trained, motivated and equipped for the job. They are happy in their work and committed to providing high standards of person centred care. The needs of residents are the focus of the staffs` attention and people looked happy and well cared for. Information about the home is readily available. People are assessed before they come to live at the home and agree a plan of care. The home works closely with other healthcare professionals. People living at the home say they enjoy it, there are activities to do, they like the staff and the food. Staff are personable and professional with good relationships. There is friendly banter from time to time and a good atmosphere. The company and manager do well to make sure there is an ongoing programme of redecoration and refurbishment so that high standards are maintained and the building is safe and clean. The home achieved a 5 star (Excellent) award for its catering facilities in September 2007. The award is made by Leeds City Council Food and Health Service who visit unannounced and check hygiene and safety, structure and cleaning and the management of the kitchen. If people do have a reason to complain, Meridian Healthcare takes it seriously and looks into the matter. What has improved since the last inspection? There has been some good work done to make sure that the issues that were raised in the last inspection report have been addressed. Work to care plans now meets requirements and each care plan has a signed agreement to the plan of care. Work is being done to introduce life histories. The home was successful in being awarded a Local Authority improvement grant and has bought new games and equipment for activities, a new large screen TV and a lot of outdoor furniture and bird feeding stations. Some areas of the home have been redecorated as part of an ongoing programme. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Acacia Court Crawshaw Hill Pudsey Leeds West Yorkshire LS28 7BW Lead Inspector Paul Newman Key Unannounced Inspection 09:30 21st February 2008 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 Acacia Court DS0000053221.V357266.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. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acacia Court Address Crawshaw Hill Pudsey Leeds West Yorkshire LS28 7BW 0113 2559933 0113 239 4588 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) Meridian Healthcare Ltd Mrs Tina Davies Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 22/02/07 Brief Description of the Service: Acacia Court provides accommodation for forty older people. It is a purpose built property and aims to offer a style of accommodation similar to that of a hotel. The home is conveniently located in the centre of Pudsey. There are a range of local amenities and facilities in the vicinity, including shops, pubs and public transport. All the bedrooms are single occupancy and have en-suite facilities. There is a large dining area and various communal lounges throughout the building, on both floors. Parking space is available and there is level access into the home. Accommodation is provided on three floors and a passenger lift ensures easy access to all. Information about the home is provided in the form of a statement of purpose and service user guide. Both these documents are available at the home, are regularly updated and outline the terms and conditions for residents. The current fees charged are £437 to £600 per week. Higher charges are for some bedrooms that are larger and include a comfortable sitting area with access to a patio area. There are additional charges for hairdressing, newspapers and private chiropody. This information was provided by the home in January 2008 and is subject to annual review. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced visit carried out by one inspector that started at 9:30 and finished at 16:30 on 21 February 2008. A brief one hour visit was made on 22 February 2008 to make some final checks. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and that the outcomes for the people meet National Minimum Standards. Before the inspection, information collected about the home over the last year was reviewed. This included looking at any reported incidents, accidents and complaints. Survey forms were sent to the home before the inspection for the manager to give out to people living at the home, visitors, healthcare professionals involved in peoples’ care and the staff working at the home. This gives people the opportunity to comment if they want to. Information provided in this way may be shared with the provider but the source will not be identified. Some of the written comments that were made in the surveys are included in the report to show what people think about the way the home is run. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information. This is a self-assessment of the service provided and gives a lot of information about how the manager thinks the home is meeting standards, how it has improved during the last year and what further improvements are intended in the year ahead. All of this information was used to plan the inspection visit. A number of documents that the home must keep up to date were looked at during the visit. All communal areas of the home used by the people who live there were checked as were some bedrooms. Time was spent talking with the people, watching what was going on, as well as talking with the manager and some of the staff on duty. The manager was given verbal feedback about the outcome of the inspection visit and provided with an analysis of the surveys that were returned by relatives. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home provides good standards of care in an excellent environment. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 7 One requirement is made. This is a regulatory matter and has no impact on the quality of service provided. It is about records that must be kept at the home with regard to complaints. Four recommendations are made that will further develop the staff and services. These are: • The manager has identified that more detail can be provided in care plans and an example was discussed. This is encouraged so that staff have clear guidance on all aspects of care delivery. More detailed daily recording should aim at showing where care needs have been addressed or where problems were encountered. The inventory of training topics shown on the training matrix that was seen during the inspection visit should be reviewed and staff given further training opportunities in areas not yet experienced. Things like deaf and visual awareness. This will further develop the skill and knowledge base of the staff team. As a discussion and staff training exercise, the manager should use the analysis of the surveys that were returned to the CSCI at the next staff meeting. For the protection of staff managing the money and so that a full audit trail can be made, that receipts are requested and kept from the hairdresser and private chiropodist. • • • 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. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 8 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 Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. People are properly assessed before admission so they can be sure the home can meet their needs. EVIDENCE: The information provided before the inspection visit that was summarised in the Annual Quality Assurance Assessment (AQAA), showed that all people considering coming to live at the home and their relatives are seen personally. A visit to the home is arranged when at least the relatives and, if possible, the prospective service user can see the room available the general facilities and Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 10 meet other people living there. They are provided with a service user guide that outlines the terms and conditions. The statement of purpose and service user guide are reviewed regularly. Three peoples’ files were checked to get a view about the detail of information that is gathered before a person is considered to come and live at the home. The files included the most recent admission. People are only admitted on the basis of a full assessment. The files showed that this includes gathering information from healthcare professionals, social workers, families and the person themselves. The manager goes to see the person to make the home’s own assessment, so by the time a decision is made the home has enough information about, activities for daily living, medical history, care needs, nutrition and mobility. Simple, but important things like personal preferences for getting up times and preferences for food, preferences for a bath or shower were identified in the assessments. In the conversations with staff it was clear that they are fully informed about peoples’ needs before they are admitted to the home. A new development since the last inspection has been the introduction of peoples’ life histories. This is a good development and helps staff with background information that gives them a better understanding of individuals’ lives and helps with day-to-day conversation and communication. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ healthcare needs are met and the care plans provide clear instruction for staff to follow so they are aware of peoples’ needs. People are protected by safe medication policies, procedures and practices. People are treated with respect and in a dignified way. EVIDENCE: Care plans are based on a pre admission assessment carried out by the manager together with information and assessments gathered from other people like healthcare professionals who have been involved in the persons care. The care plans that were checked showed that information had been accurately used from the pre-admission assessment so that needs were Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 12 identified and then reviewed regularly. The plans included activities for daily living, risk assessments for moving and handling and nutrition. The involvement of the family and person about their life history, likes and dislikes, preferred ways of living and routines, is a way to make the care plans more person centred and helps staff deliver care in an individual way. It was clear that the plan of care had been discussed with each individual and they had signed to agree to the plan. The AQAA that was completed by the manager identified that the detail of this kind of recording is an area of development that the staff team will work on over the next year. One example of the kind of development that should be done was discussed with the manager. This was for a person who is currently being reassessed for a more appropriate care setting and who can be challenging and aggressive in their behaviour with staff. Although this was identified in the plan there could have been more detailed advice to staff about any indicators of aggression and strategies to deal with and calm the person. Daily monitoring notes could also offer more detail that focuses on the agreed plan of care. There was evidence of involvement with healthcare professionals, like the Community Nurse, Community Psychiatric Nurse and Doctors. Records were completed well and it was easy to track where staff began to identify health problems, made a referral and there was good documentation of the diagnosis and advice that should be followed. In one conversation a person said that they had approached the manager the day before the inspection visit to arrange see the doctor after they had read an article about a medical condition in the newspaper. The doctor visited during the inspection and allayed her fears. In the case tracking that was done, it was noted that one person had some health problems that had been referred to the doctor and there had been changes in the plan of care and medication. This was clearly documented. Staff were asked about this to make sure that they were up to date and knew about these significant changes. All of the care staff on duty were fully informed. Medication procedures and practices were discussed and observed and were safe. The facilities for the storage of medication, the recording of the administration of drugs, including controlled drugs and the disposal of medication were checked and found to be sound. In the time spent watching what was going on the staff seemed organised and efficient in making sure people got the attention and care they needed. Staff were personable and professional and relationships appeared good with some friendly banter from time to time. There were examples of good practice in making sure that peoples’ dignity was maintained. Clothing was clean and all of the residents looked well cared for. Staff were careful to make sure doors were closed at times when personal care was delivered and were seen knocking on doors before entering rooms. They were attentive to people and some overheard conversations showed staff had a nice manner that people appreciated. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 13 The number of surveys that were returned to the CSCI for people to comment on the service was disappointing, but we were unaware that they were sent at a time that Southern Cross was also conducting a satisfaction survey. These were analysed for the manager to consider and discuss with the staff team as there were some comments that staff should take notice of like - ‘My relative is compos mentis and would like to be spoken to as an equal. Sometimes she is spoken to as you would a child’, and ‘As in any organization the quality, ability, training and experience of staff ultimately makes the home what it is. This could be improved at all levels where a little more understanding and better attention to detail could deliver a great deal’. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. Peoples’ social expectations and personal preferences are met and they are able to exercise choice in their lifestyles so they can be as independent as possible. People living at the home are provided with a varied and nutritious diet so they can eat healthily. EVIDENCE: There is a programme of activities that is displayed around the home. The notice also encourages people to make suggestions for new things to do. On the day of the inspection visit one of the visiting activity organisers was due and staff were overheard reminding people of the event. The relative of one person living at the home offered to be a volunteer and following proper checks and vetting, has added to the range of activities that are provided inhouse. People said that they could choose what to join in but some said that they were happy being in their rooms listening to the radio, reading or watching TV. The home was successful in being awarded a Local Authority Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 15 improvement grant and has bought new games and equipment for activities, a new large screen TV and a lot of outdoor furniture and bird feeding stations. Links with the local community are encouraged. The home was successful and community spirited as being a centre for a Radio Aire Christmas toy appeal. Local clergy visit and there is a religious service each month and occasionally, local school choirs come in to entertain. People have telephones installed to enable them to keep in contact with their family and friends when they wish. Visitors are welcome at all times and the home’s written information makes this clear. The people spoken with said that the food was generally good. They talked about having choices and about being able to talk about meals in residents meetings. The manager said that they made changes to the menus at peoples’ request. The main meal of the day was seen. The dining room/restaurant was attractively set out and people were not rushed, assisted and encouraged where necessary. It was a social occasion with conversations going on around the room. When talking with one person in their bedroom, the door was knocked and when invited in, a carer entered to go through the choices for the tea and main meal next day. When asked was it a problem to order for the next day she said ‘not really, sometimes I forget what I have ordered, but someone reminds me’. The home achieved a 5 star (Excellent) award for its catering facilities in September 2007. The award is made by Leeds City Council Food and Health Service who visit unannounced and check hygiene and safety, structure and cleaning and the management of the kitchen. Acacia Court DS0000053221.V357266.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgment using available evidence including a visit to this service. The people who live at the home and their relatives know how to complain and feel confident that they will be listened to and that appropriate action will be taken when necessary. There are adult protection procedures that staff are aware of and understand. People can be assured that they can feel safe at the home. EVIDENCE: The manager said that the home encourages people to air views and concerns at an early stage so that staff can act upon this and resolve things quickly. Shortly after the last inspection concerns were expressed by two relatives to the CSCI. The matters were referred to Meridian Care and properly investigated with the complainants being satisfied with the response and outcome. Although the CSCI was provided with all the documentation about these complaints copies were not available for inspection at the home but must be. The manager said these were archived. Just prior to this inspection visit the CSCI received a further anonymous complaint and all of the matters were checked at the inspection visit but none were substantiated. Everyone spoken to during the visit said that staff were approachable, listened and wanted to make sure people were happy and that they felt comfortable in raising things. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 17 Written comments made in surveys returned by people living at the home and their relatives indicated that they know the complaints procedure. One written comment however, said – ‘Occasionally the responses refer to ‘head office’ edicts rather than a real explanation’. Policies and procedures are in place for the protection of vulnerable adults and staff have been given training on this. The training includes indicators of abuse and whistleblowing. There was evidence of recent training and further training planned for staff that includes a company initiative to make sure all staff in post complete a safeguarding adults awareness workbook. Acacia Court DS0000053221.V357266.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 26. People who use the service experience excellent quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People live in a safe, comfortable and well-maintained environment that is pleasant, clean and hygienic. EVIDENCE: A tour of the building was made so that all the communal areas, laundry, kitchen and some bedrooms could be checked. The gardens were also seen. Two of the surveys returned made specific comments about the environment. These were: • • ‘The property is well presented and maintained’. ‘The home is very clean, well furnished and well kept’. DS0000053221.V357266.R01.S.doc Version 5.2 Page 19 Acacia Court During a long conversation with one person she said that her room was always kept clean and tidy. The bedrooms seen were personalised and some had telephones. The general feeling walking around the home is that is very well looked after and maintained. Bedrooms are comfortable and some have direct access to patio areas. All bedrooms are ensuite and there are well equipped communal bathrooms that make things safe for people living at the home and staff assisting them in personal care. The home is easy for people to get around; the corridors are wide so getting about with a walking stick or zimmer can be done with reasonable ease and safety both for the individual and other people. The large entrance hall has some easy chairs and these always seemed to be occupied by people who like to see who was coming and going and enjoyed some friendly banter with visitors. There are plans to develop the current activities room and an adjacent storeroom into a larger room that will double up as a lounge/activities room. The domestic staff do well to maintain an environment that is free from unpleasant odours and is very clean and tidy. The company and manager do well to make sure there is an ongoing programme of redecoration and refurbishment so that high standards are maintained. The laundry is well equipped and appeared organized with systems to make sure that items do not go missing. The gardens are well maintained and a team of gardeners were maintaining the grounds on the day of the inspection. All the bedrooms have a view of some part of the garden, some have direct access to patio areas. There is good quality garden furniture situated around the home and bird tables and feeders have also been placed around the garden at the request of people living at the home. The AQAA completed by the manager gave information about the maintenance and checking of the services and equipment and records are kept at the home of the regular checks that are made. The home has good links with the infection control and environmental health nurses. Outbreaks of infection are reported to the relevant agencies without delay. Advise is sought and steps taken to safeguard and protect the residents of the home. Staff were seen to wear protective clothing and use bacterial hand washes to reduce the risk of cross infection. They said that there was always a good supply of these items. Acacia Court DS0000053221.V357266.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. People living in the home are cared for by experienced staff who are organised, properly recruited, trained and qualified for the job. EVIDENCE: During the two visits to the home made for this inspection, there appeared to be enough staff on duty, based on the levels of dependency that were seen. The AQAA stated that rotas and staffing levels are based on the needs of the people and staffing levels have increased during the morning period since the last inspection, to give the head of care more supernumerary hours and more time for activities. The care staff were focused on care tasks and were supported by domestic staff including someone dedicated to the laundry and the chef. The manager was supernumerary. An activity organiser also came for part of the day. There has been stability with full time care staff but some turnover with part-time carers and this may account for some of the comments made in the surveys returned by relatives. All of the people spoken with during the visits praised the staff and felt cared for. Staff on duty were personable and professional in the way they related with each other and with people living at the home and there was a good atmosphere. One written comment made in a survey stated: Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 21 ‘As in any organization the quality, ability, training and experience of staff ultimately makes the home what it is. This could be improved at all levels where a little more understanding and better attention to detail could deliver a great deal’. Another stated: ‘Generally there is a lack of attention to detail which would make a difference to the quality of life for all the residents. I would like to see a little more thought and care’. As a consequence the levels of staff training provided were checked. All of the care staff on duty were spoken with and all had completed safe working practice training with updates where necessary. The chef confirmed that she had completed the advanced food hygiene certificate. The training record (matrix) seen, showed that most staff have completed additional training in nutrition, dementia care, care planning, the protection of vulnerable adults and infection control. Senior staff who handle and administer medicines have completed training in the safe handling of medicines. The training matrix is a quick way of identifying individual staff who have not done a specific piece of training and the manager is aware of this and can make sure it is programmed. It was also noted that the matrix had some good and relevant topics like deaf awareness that no staff have completed and it is recommended that as part of the ongoing development of the skill and knowledge base of the home that staff are given the opportunity to attend sessions. The AQAA stated that twelve staff have completed a National Vocational Qualification (NVQ) with another seven working towards an NVQ. When they complete, and this is expected to be during the summer, the home will exceed the National Minimum Standard targets. There was evidence in the AQAA, records kept and from direct conversation with staff to show that they are trained and generally experienced, However, a copy of the analysis of the surveys that were returned including any written comments (made anonymous), was given to the manager. A recommendation was made that this goes for discussion at a staff meetings so that ‘attention to detail’ and what that might mean, can be explored. Personnel files for the three most recent staff appointments were checked to make sure that required documentation was complete including references and checks with the Criminal Records Bureau. The files were organised and complete with all the required information. Acacia Court DS0000053221.V357266.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed. The opinions and interests of the people are central to the way the home is run and there is a clear approach to resident care that is increasingly person centred and is the focus of staff practice. Regular auditing and checking of facilities, equipment and services make sure the home is a safe place to live. EVIDENCE: The manager is experienced and appropriately qualified. Since the last inspection she has attended a residential course for her continuing professional Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 23 development. People spoken with said that she listened and got things done. Staff said she was good to work with and had high standards. On arrival and at the start of the inspection, the manager was holding a senior staff meeting. Staff confirmed that there are regular senior and general staff meetings. Resident/relative meetings are also held and this is a useful forum to express views and make suggestions. Minutes of the meetings are kept. Comment cards are available for residents and visitors to complete at any time with suggestions and ideas about how the service can be improved for people living at the home. Meridian Healthcare also sends out satisfaction surveys to relatives. Although not seen, the manager reported that these have been positive. The Company makes regular audits of the service that include monthly visits and reports by the operations manager. These serve to make sure that the home is operating within the law and achieving National Minimum Standards. Where shortfalls are found action is taken. Monthly reports made by the operations manager are forwarded to the CSCI. This gives confidence the company is serious in maintaining and improving standards. The home keeps small amounts of money for safekeeping for some people. The systems were discussed, records checked and a cash reconciliation made for one person. This was correct. It was recommended for the protection of staff managing the money and so that a full audit trail can be made, that receipts are requested and kept from the hairdresser and private chiropodist. Records of fire safety checks were seen and these were up to date. Accident records were also seen and it was good to see a monitoring sheet for each person so that things could be monitored. It was also good to see that the home had the latest guidance on ‘Handling Medicines in Social Care’. Although hot water temperatures are regulated and checked on a regular basis, each room with a hot water tap has a digital thermometer that staff are required to use as an additional safety check. The risk assessment file was not checked in detail but it was noted that there was an assessment for the recently purchased garden furniture. Training records showed that staff are trained in safe working practices and updated where necessary. Acacia Court DS0000053221.V357266.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 3 X X 4 4 4 4 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 3 3 X 3 X X 3 Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 17(2) Sch 4(11) Timescale for action A record of all complaints made 30/04/08 by any service user or representative and the action taken must be held at the home. This is to provide evidence that complaints are taken seriously and dealt with properly. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The manager has identified that more detail can be provided in care plans and an example was discussed. This is encouraged so that staff have clear guidance on all aspects of care delivery. More detailed daily recording should aim at showing where care needs have been addressed or where problems were encountered. The inventory of training topics shown on the training matrix should be reviewed and staff given training opportunities in areas not yet experienced. This will DS0000053221.V357266.R01.S.doc Version 5.2 Page 26 2 OP30 Acacia Court 3 OP30 4 OP35 further develop the skill and knowledge base of the staff team. As a discussion and staff training exercise, the manager should use the analysis of the surveys that were returned to the CSCI at the next staff meeting. This will make sure that staff area ware of peoples’ views and can address any shortfalls. For the protection of staff managing the money and so that a full audit trail can be made, receipts should be requested and kept from the hairdresser and private chiropodist. Acacia Court DS0000053221.V357266.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Acacia Court DS0000053221.V357266.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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