Care Home: Acorn Care Home

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What the care home does well The home is fully staffed and there is a stable staff team that residents say are kind and caring. More than half of the staff team have got NVQ qualifications and have had the training needed to help them to provide a good service for the residents. There is a relaxed atmosphere in the home and relatives are welcomed. Families are invited to any celebrations or events organised at the home. Activities are organised daily according to the residents` choices. One resident said "the home is very comfortable." When asked what the service does well a staff member said, "it supports the staff very well and meets the client`s needs." What has improved since the last inspection? All the requirements made at the previous inspection have been addressed and are now met. Activities continue to improve, as do the opportunities for residents to go out. Staff receive ongoing training and are knowledgeable and able to meet the needs of the residents. What the care home could do better: The manager and staff team continue to work to provide a good service for the residents and to meet each person`s needs. The requirements in the previous inspection have been met. Two requirements and two recommendations have been made from this visit regarding controlled Drugs, which must be stored in a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973. The registered person to provide facilities and services for residents so that they can live in a safe, well- maintained environment. A programme of re decoration and refurbishment to be provided to CSCI with clear dates by which work will commence. It was suggested to the manager that she uses the Key Lines of Regulatory Assessment (KLORA) to assist and continue to identify and evidence the excellent quality of the service provided. CARE HOMES FOR OLDER PEOPLE Acorn Care Home 83 Blythswood Road Seven Kings Ilford Essex IG3 8SJ Lead Inspector Ms Harina Morzeria Unannounced Inspection 12th August 2008 10:00 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 Acorn Care Home DS0000025881.V369415.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. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acorn Care Home Address 83 Blythswood Road Seven Kings Ilford Essex IG3 8SJ 020 8597 1793 020 8597 1793 ssoor@hotmail.co.uk 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) Mrs Sarbjit Soor Mrs Sarbjit Soor Care Home 3 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (3) of places Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to residents of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of residents who can be accommodated is: 3 Date of last inspection 28th February 2007 Brief Description of the Service: Acorn Care Home is a care home providing personal care and accomodation for three older people and is registered to care for people with dementia. The home is a corner house, in a residential area of Ilford, close to a busy main road and within easy reach of local facilities and transport links. All the bedrooms are located on the first floor and a stair lift is available for easy access. There is a separate lounge and dining area downstairs, with a small well-maintained garden to the back of the house, which is accessed via the dining room as well as the kitchen. There is a communal bathroom and toilet upstairs as well as a shower facility and toilet downstairs. At the time of the inspection, the range of fees for the home were between £420.00 and £510.00 per week. A copy of the Statement of Purpose and Resident Guide to the home are made available to both the residents and their family/representatives. A copy of the most recent inspection report is available on request. Acorn Care Home DS0000025881.V369415.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 that people who use the service experience good quality outcomes. This inspection was unannounced and took place over approximately seven hours. The manager was present and assisted with the inspection. The inspector looked around the home, spoke to the residents, staff, relatives and observed the lunchtime routines at the home. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. Staff, care and other records were checked. Feedback questionnaires were sent to residents, relatives and staff and a good response was received. Additional information relevant to this inspection has been gained from the Annual Quality Assurance Assessment and Regulation 37 notifications. The Commission has not received any complaints about this service. The inspector spoke to the quality manager for the London Borough of Havering to get feedback about the quality of the service, who stated that they do not have any issues of concern to report. The inspector had a discussion with the manager on the broad spectrum of equality & diversity issues and she was able to demonstrate an understanding of the varied needs of the residents around religion, sexuality, culture, disability and gender. What the service does well: What has improved since the last inspection? All the requirements made at the previous inspection have been addressed and are now met. Activities continue to improve, as do the opportunities for residents to go out. Staff receive ongoing training and are knowledgeable and able to meet the needs of the residents. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Acorn Care Home DS0000025881.V369415.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 Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Prospective residents and their relatives have detailed information on the home, which assists them to make an informed choice about moving into Acorn Care Home. A pre-admission assessment is undertaken of all prospective residents; this will ensure that their identified needs can be met appropriately by the home. Prospective residents and their relatives are able to visit the home prior to their admission. EVIDENCE: The Statement of Purpose has been revised and is available to all residents and relatives. The service users’ guide is in a pictorial format, informative and written in plain English. It contains the terms and conditions in respect of the Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 9 accommodation, the service that will be provided and the complaints procedure. Residents have their own copy of the Service User Guide. These documents can also be available in different formats and languages upon request. There have been no new admissions to the home since the last inspection. As at the previous inspection the file of the most recently admitted resident was examined and there was evidence that prior to admission, the manager had visited the prospective resident and an assessment had been completed. These assessments had been completed with information obtained from the resident (where possible), relatives, social and health care professionals and also included information on people’s social care wishes and aspirations. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. It was evident that prospective residents are given the opportunity to spend time in the home. New residents are provided with a statement of terms and conditions. This sets out in detail what is included in the fee, the role of and responsibility of the provider and the rights and obligations of the individual so that residents know what they can expect. The home is not registered to provide intermediate care. Acorn Care Home DS0000025881.V369415.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The health and personal care needs of each resident are set out in individual care plans. These plans provide staff with detailed information, which ensures that residents’ health and personal care needs are met on a daily basis. There are medication policies and procedures for staff to follow and medication records are being completed correctly. This safeguards the residents with regard to the administration of their medication. Residents are treated with respect and arrangements for their personal care ensures that their right to privacy is upheld and particularly at the time of death they are treated with sensitivity and respect. EVIDENCE: Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 11 The files of all three residents were viewed and all had a person centred care plan. There was evidence that residents and/or their family are involved in drawing up the care plans. Reviews take place on a monthly basis, or more frequently if necessary. There was some evidence of life histories and this needs to be developed further. Obviously, the successful development of life stories will need the involvement of relatives because some residents who are living with dementia may not be able to remember some significant events in their lives. All of the residents have care plans, which give details of their needs and how to maintain their independence as far as possible. Individual plans clearly record people’s personal and healthcare needs and detail how they will be delivered. The care plans identify residents’ strengths and capabilities and how their needs should be met. They also contain information about residents’ likes and preferences. Each resident has a nominated key worker. The care plans are used as working tools and are reviewed and updated when a person’s needs change. They therefore contained up to date information to enable staff to meet residents’ current needs. Residents are registered with local GPs. The optician and dentist make regular checks. The district nurse visits as and when required to provide nursing support. Residents’ weight is monitored and dietary needs addressed. Manual handling assessments are in place. Aids and equipment are provided to encourage maximum independence for people using services, these are regularly reviewed and are replaced to accommodate changing needs. Specialist advice is sought by the home to ensure residents’ needs are met effectively. For example, for one resident who is registered partially sighted, the manager contacted the local RNIB group to seek advise and guidance about support services available locally. Audio books have been obtained and guidance is sought about how staff may best be able to meet her needs further. Medical information is recorded and the outcome of visits to the doctor or hospital and any follow up action is recorded. Residents are supported to attend doctors and hospital appointments. The manager arranges training on health care topics that are related to the health care needs of the residents to make sure that staff are trained and competent in health care matters relevant to the needs of the people who use the service. The home is registered as a service for people with dementia and staff assist residents appropriately as they have all received dementia care training. Staff were talked to and observed to treat residents in a respectful and sensitive manner. They understood the need to promote dignity through practices such as the way they addressed residents, knocking on their bedroom doors before entering, talking to the residents and reassuring them when assisting them. Residents’ privacy and dignity are covered during the staffs’ induction programme. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 12 None of the residents can self medicate and medication is administered by staff that have received medication administration training. There are policies and procedures for the handling and recording of medication. The Medication Administration Record (MAR) charts were examined and these were appropriately completed. The medication records include a photograph of the resident, a medical history and details of any allergies. All regular medication is appropriately and safely stored in a locked cupboard in the kitchen and liquid medicines have the opening dates recorded on them. There are regular times for administering medication. Medication is safely and appropriately administered in a way that meets residents’ individual needs and preferences. However, the home do have a stock of controlled drugs prescribed for one resident, which are inappropriately stored under the new regulations. See requirement. The home has a policy, procedure and practice guidance to help staff when caring for residents with degenerative conditions, terminal care and death. All staff receive in-house training and practical advice and have support and opportunities to discuss any areas of anxiety and concern. The manager should consult with each resident and their relatives regarding the process of drawing up end of life care plans in order to establish their wishes regarding dying and death and record as to whether they wish to remain at the home or go into hospital at the end of their life. Acorn Care Home DS0000025881.V369415.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, 15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The residents are able to participate in an activities programme, according to their choices and capacity. Visiting times are flexible and visitors are made to feel welcome. This ensures that residents are able to maintain contact with families and friends. Residents are able to exercise choice and control over their lives. The meals are well presented and nutritionally balanced and offer both choice and variety to the residents. EVIDENCE: Residents were asked their views and care plans and other records were examined. The care plans contain information about residents’ social and spiritual activities. Activities include: armchair exercises, games, manicures, hairdresser, sing alongs and listening to music, staff reading the daily news paper to the residents and discussing current issues with them, walks in the park, which are particularly enjoyed by one resident who has dementia, going shopping, going to the local theatre every other month (recently watched Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 14 South Pacific) and going to tea dances held at various venues locally. One of the residents is visited by a pastor who conducts a service for her. Residents spoken to said that they enjoy the activities. Staff take the residents out to the local shops or other activities subject to a risk assessment. There are photographs of the various activities and outings the residents have enjoyed over the year. The manager hopes to display these in the hallway. A hairdresser visits once per week and ensures that the ladies have their hair done. This is a small home for three residents and the inspector observed that the manager and staff constantly seek the residents’ opinions, talking to them and providing a flexible service in order to meet their needs. Hence, residents are encouraged to be as independent as possible and to be involved in choices about the home and about their lives. Visiting times are flexible and relatives and friends can visit at any time. This was confirmed by the residents. At the time of this inspection, the inspector was unable to gather views from any visitors as no one was visiting at that time. Residents are offered a choice of meals. Special diets are catered for. Meals are served in the dining area and drinks and snacks are available. The residents all said they enjoy their food. Assistance and encouragement was given to residents who needed help. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents and relatives can be confident that their concerns and complaints will be listened to and acted upon. There are policies and procedures on safeguarding adults and staff have undertaken training, which ensures there is an appropriate response to any allegations or concerns regarding abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. Complaints are recorded and dealt with by the manager and the staff team. Residents and relatives are encouraged to voice any problems so that they can be sorted out as soon as possible. Staff are reminded to record any complaints so that they can be appropriately dealt with. The complaints book was examined and no complaints were recorded in this. The manager has reviewed the home’s safeguarding policy and procedure which clearly tells staff the actions to take in the event of abuse/suspected abuse being discovered. All staff working in the home have received safeguarding adults training as part of induction training and know how to respond in the event of an incident being reported. A recently appointed Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 16 member of staff spoken to was aware of the issues surrounding safeguarding adults and aware of their responsibility to residents. Staff, residents and relatives feel able to raise any concerns that they might have. There is a clear system for staff to report concerns about colleagues and managers which ensures that concerns are investigated in line with local policies and procedures. However, the manager has been advised to send staff on external safeguarding adults training which she has agreed to do. See recommendation. There have been no safeguarding issues reported to the CSCI inspector since the last inspection. The manager stated that they do not handle any finances on the residents’ behalf, except personal allowances. All receipts are kept and sent to the relatives/representatives who deal with the residents’ finances. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25,26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The residents live in a clean, comfortable and hygienic home that has suitable aids and adaptations for their needs. Residents have access to indoor and outdoor facilities. The home is in reasonable decor, however a programme of redecoration and refurbishment is needed. There are sufficient toilets and bathrooms situated on both floors. EVIDENCE: Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 18 The home is in Goodmayes in Ilford, near local shops and amenities as well as a park. It is not accessible to wheelchair users. On the ground floor there is a lounge/dining area and all three bedrooms are on the first floor accessed by a stairlift. There is also a walk - in shower and toilet downstairs. Grab rails, support frames and walking frames are available for residents that need these. Therefore, the equipment needed to meet the residents’ specialist needs is available in the home. Although the home is in a reasonable state of decor, it is looking tired and a lot of areas need to be ‘freshened up’. A programme of renewal and re-decoration is needed. There is a small garden at the rear of the home which is accessible from the dining room and is enjoyed by the residents during fine weather. At the time of the inspection the home was clean and free from offensive odours. There is an infection control policy and advice is sought from external specialists if the need arises. All staff have received infection control training and the manager aims to raise staff awareness of this issue further in the coming year. All the residents’ bedrooms were clean, tidy and free from any offensive odours. Residents are encouraged to bring some of their own furniture and personal possessions with them. Hence, the bedrooms were personalised with radios, photographs, pictures, cuddly toys and ornaments. Most of the bedroom furniture and soft furnishings (curtains, carpets and bedspreads) were in good repair. However, some attention is required to two of the bedrooms; where the carpet was raised making it a safety risk for the residents, this was immediately brought to the manager’s attention who agreed to have the carpets pulled/straightened to remove the hazard. The manager should consider replacing these carpets as part of the home’s programme for renewal and redecoration. See recommendation. Although the home is comfortable, a lot of the areas are looking tired and in need of redecoration. There must to be a programme to improve the decoration, fixtures and fittings. It is important that the home is safe and well maintained. This is a requirement. There are sufficient toilets and bathrooms on both floors and all were seen to be clean and all equipment in good working order. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 19 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 this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents are supported and protected by the homes recruitment practice. Staffing levels are appropriate to support the needs of people who use the service. Staff receive the necessary training, supervision and support in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that know them well and who are committed to providing a good quality service. EVIDENCE: At the time of the visit there were three residents living at the home. There are three shifts for staffing the home. Sufficient staff are employed and the rotas are compiled imaginatively to cover for busy periods. There is generally a stable staff team and agency staff have not been used in the recent past. Hence, the home is fully staffed and any additional shifts are usually covered by the staff team. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 20 Staff files were examined and they showed that all of the relevant recruitment procedures had been adhered to; all files had a completed application form, two written references, satisfactory Criminal Records Bureau checks and copies of passports and National Insurance details. All newly appointed staff undertake an induction programme and this was evidenced for one new member of staff recently recruited. Therefore, residents receive a consistent service from a staff group that are aware of their needs and how to meet them and residents get continuity in their care. The staffing arrangements are sufficient and flexible to meet the changing needs of residents. The views of residents who contributed to the inspection was that the staff were available to attend to them and meet their needs. One resident said “staff are always around if you need them”. From observation the staff showed a caring and helpful attitude towards the residents. Training that has been undertaken in the past twelve months includes; medication administration, food & hygiene and training in advanced dementia care. The manager is going to book Mental Capacity Act and Safeguarding adults training. The newly appointed member of staff is going to enrol on the NVQ 2 course as well as attend food hygiene training , dementia awareness and safeguarding adults. All other staff are either NVQ 2 or NVQ 3 trained. No adverse comments have been received from the staff feedback questionnaires. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36,37, 38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents live in a home that is run in their best interests by an experienced and qualified manager. Residents’ financial interests are safeguarded by the policies and procedures of the home. The manager and the staff team work well together and staff receive appropriate support to make sure that residents are safe and secure whilst living at Acorn Care Home. Residents and staffs’ health and welfare are promoted and protected. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager is registered as a “Fit Person” by the Commission’s registration team, she is also the proprietor of the home. The manager is experienced, appropriately qualified and has completed the Registered Manager’s Award. Although she undertakes regular training and understands and values opportunities for continuing professional development she has been advised by the inspector to attend external events in order to gain information and keep up to date about current developments in the social care field . The registered manager is competent to run the home and meets its stated aims and objectives. The atmosphere in the home is relaxed and friendly and there is a stable staff team. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of best practice operational systems particularly in relation to continuous improvement, customer satisfaction and quality assurance. There is an appropriate policy and procedures regarding the safeguarding of residents’ finances. The home only holds small amounts of money for hairdressing, chiropody, toiletries and other small sundries. Receipts are kept and forwarded to the residents’ families. Towards the end of the inspection the manager was observed leading from the front, by directly engaging with residents and staff. Residents and relatives were complimentary and all of the staff that were spoken to spoke very highly of the management team and how well they felt supported by them. Residents and relatives are asked for their feedback about the service and improvements are made where gaps are identified. The AQAA contains clear, relevant information that is supported by appropriate evidence. The manager recognises the areas that they still need to improve and has detailed ways in which they are planning to do this. There was evidence that staff are receiving regular supervision. Annual appraisals, regular staff meetings and direct observations of staff care practices are taking place. This was confirmed by staff and records of these meetings were seen. The manager was able to demonstrate her knowledge and commitment to equality and diversity issues, which are given priority in caring for the residents. In the main, record keeping is of a good standard, with records being kept securely in accordance with the Data Protection Act. All of the working practices are safe, within a risk management framework. The home has a range of policies and procedures to promote and protect residents’ and employees’ health and safety. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 23 The manager is proactive with regards to health and safety to ensure that any potential risks are minimised as far as possible. Health and safety awareness issues are cascaded to staff to raise their awareness. Regular health and safety checks are carried out by appropriate professionals. The manager is aware that it is her responsibility to carry out all of the necessary health and safety checks and provide a safe environment for the residents and staff at all times. The manager proactively monitors the home’s Health & Safety performance and consults other experts and specialist agencies when necessary. Risk assessments were in place for fire, first aid, infection control and moving and handling. At the time of the inspection there were no issues relating to Health & Safety, which means the residents’ safety is assured. Acorn Care Home DS0000025881.V369415.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Acorn Care Home DS0000025881.V369415.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 OP9 Regulation 13(2) Requirement The registered person must ensure that controlled Drugs, including Temazepam, must be stored in a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973. The registered person to provide facilities and services for residents so that they can live in a safe, well- maintained environment. A programme of refurbishment to be provided with clear dates by which work will commence. Timescale for action 30/11/08 2. OP19 16 30/11/08 Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 26 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 OP11 OP30 Good Practice Recommendations ‘End of Life’ care plans must be developed for all residents. The registered manager to ensure that staff are given the opportunity to attend external training courses such as Mental Capacity Act Training and Safeguarding adults, which are provided free by the London borough of Redbridge Learning Collabrotive. Acorn Care Home DS0000025881.V369415.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Acorn Care Home DS0000025881.V369415.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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