Care Home: Acre Green Nursing Home

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What the care home does well The home is well managed and the interests of the people who live there are the main concern of the manager and staff. The staff are well organised. They have a good knowledge of the people they care for. They create a good atmosphere in the home that is warm and friendly but always professional. Good activities are provided and there are links with the community. The current cycle of menus seen showed there is choice, variety and good nutritional value. The home now uses a system called `Nutmeg` adopted by Southern Cross so that the nutritional value of each meal can be calculated. Relationships are good and people are confident in the staff and feel able to raise any concerns they might have. Visitors are free to come and go as they wish and feel welcomed into the home. What has improved since the last inspection? What the care home could do better: The home identified improvements it wants to make over the next year in the AQAA that was provided. These will further maintain and improve services and we will monitor progress. As a direct consequence of this inspection visit two requirements are made. These concern the consistent recording of medication that has been prescribed particularly creams and the recording of staff duty rotas that must accurately reflect the staff that have worked a shift. A recommendation is made suggesting that only medication requiring storage at cold temperatures should be kept in the fridge. CARE HOMES FOR OLDER PEOPLE Acre Green Nursing Home Acre Close Middleton Leeds Yorkshire LS10 4HT Lead Inspector Paul Newman Key Unannounced Inspection 1st October 2008 08:00 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 Acre Green Nursing Home DS0000001317.V372632.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. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Acre Green Nursing Home Address Acre Close Middleton Leeds Yorkshire LS10 4HT 0113 2712307 0113 2714965 acregreen@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Management Limited 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) Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2), Terminally ill over of places 65 years of age (2) Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2007 Brief Description of the Service: Acre Green is a 50 bedded care home with nursing beds. The two storey home is built around a central courtyard and provides residential care in the 20 beds on the ground floor and nursing care and higher dependency care in the 30 beds on the first floor. All rooms have en suite facilities. The two floors are staffed and operate as separate units with a nurse on duty 24hrs on the first floor. The kitchen and laundry for both units are on the ground floor with a small serving kitchen on the first floor. Each floor has two lounges and a dining area. A passenger lift provides access between the floors. The central courtyard provides a safe sitting area and land to the side of the building is landscaped to offer additional outdoor space for the use of residents and their families. There is a generous parking area in front of the building. The home is situated in the centre of a residential area in Middleton on the outskirts of Leeds on the site of a former local authority residential home. Local community facilities include a health centre, library, bowling green, day centre, club, shop and a school. A large retail shopping mall is approximately five minutes drive from the home. Further details about the care and services provided can be found in the home’s statement of purpose and service user guide and these are readily available at the home. The current weekly fees charged by the providers are £410 to £436 for care without nursing and £436 to £525 with nursing. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection during the site visit made in October 2008. Acre Green Nursing Home DS0000001317.V372632.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. The accumulated evidence in this report has included: • The previous key inspection and an Annual Service Review. • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • Relevant information from other organisations. • What other people have told us about the service. • Information obtained from people living at the home, relatives, staff and other health care professionals. One inspector made an unannounced visit to the home that lasted seven hours on 1 October 2008. A Pharmacy Inspector, who specifically looked at medication policies, procedures and practices, accompanied this inspector for part of the day. During June 2008 the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment that if completed properly, should give us a lot of information about how the home is operating and what is planned for the future. It tells us where we can find evidence that the home is meeting National Minimum Standards. The AQAA that was returned was clear and gave us good information that helped plan the inspection. During the visit, a number of documents were looked at and all communal areas of the home used by the people and some bedrooms were inspected. . Time was spent with the manager and the operations manager who was contacted and came later during the morning. A good proportion of time was also spent speaking to the staff on duty, people who live at the home and visitors. Time was also spent in communal areas and the dining rooms, watching what was going on and checking whether people appeared comfortable and cared for. Acre Green Nursing Home DS0000001317.V372632.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 identified improvements it wants to make over the next year in the AQAA that was provided. These will further maintain and improve services and we will monitor progress. As a direct consequence of this inspection visit two requirements are made. These concern the consistent recording of medication that has been prescribed particularly creams and the recording of staff duty rotas that must accurately reflect the staff that have worked a shift. A recommendation is made suggesting that only medication requiring storage at cold temperatures should be kept in the fridge. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 7 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. Acre Green Nursing Home DS0000001317.V372632.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 Acre Green Nursing Home DS0000001317.V372632.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. People have up to date written information about the home to help them decide if the home is suitable for them to live in. People are properly assessed before admission so all concerned can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The surveys that were returned during June 2008 and conversations during the day of this visit indicated that people are provided with enough written Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 10 information about the home. The home has updated the service user guide and statement of purpose that are displayed in the entrance foyer and also available to anyone on request. These contain up to date information and will help people get an idea of what facilities and services the home provides. Three care plans were checked during the day. One of these was for the most recent admission. All had a pre-admission assessment that was supported by additional social work assessments and care plans. The home has now begun to involve other staff in the pre admission process and developing their confidence in making what are sometimes difficult decisions about whether the home can meet the person’s needs. On admission each service user or their next of kin signs a contract containing the terms and conditions of their stay at Acre Green. From the information gathered in the pre-admission assessment a plan of care is written. Acre Green Nursing Home DS0000001317.V372632.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, 10 and 11. People who use the service experience good quality outcomes in this area. People get the care they need and the care plans provide instructions and guidance for staff to follow so they are fully aware of peoples’ needs. People are treated with respect and in a dignified way. There are good systems in place for the storage and record keeping of controlled drugs. This makes sure there is a complete record of these drugs entering and leaving the home. However records of administration for medicines such as creams are not always completed. This makes it difficult to know if a person has received their medication as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 12 The three case files that were checked showed that information had been accurately used from the pre-admission assessment to draw up the plan of care. People and their relatives spoken with during the visit confirmed that they had been involved. The plans addressed individual health and personal care needs. The plans offered sufficient guidance to staff for them to know what each person’s care needs are, and how they should go about addressing these. Additional training and supervision has been given to staff involved with care planning. The home has been trying to develop the care plans to make them more ‘person centred’ so that there is a lot more information about peoples’ personal preferences, preferred lifestyle and their life history. There was evidence of this on the files seen. Speaking to staff, it was clear that they know the people they care for very well. On admission, a range of risk assessments are made for moving and handling, nutrition, dependency and pressure sore risk. These are reviewed regularly. People have their weight recorded at least monthly and there was evidence to show that any significant changes are referred to the GP. Other healthcare professionals are consulted when required and these include the dietician, tissue viability nurse, and community psychiatric nurse. All personal care and visits from healthcare professionals and Doctors are carried out in the privacy of people’s own bedrooms. During the inspection, staff were seen knocking on bedroom doors and making sure that doors were closed at times when personal care was being delivered. People spoken to said that that staff are attentive to their needs and wishes. The care plans now include arrangements for the care of people who may be coming to the end of their life. Staff have been trained in palliative care and the home has been part of a group who work with the Gold Standards Framework for palliatives care with the local doctors and the Leeds palliative care team within the Middleton area. Some positive comments made by people and their relatives reflected good standards of care with staff being ‘supportive’, ‘keep us up to date with problems’, ‘staff are very caring and approachable’, ‘My mother always looks well cared for’. The Pharmacy inspection was detailed and thorough. The current Medication Administration Records (MARs) were looked at on the residential and nursing units. There was a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to know who was involved in medication administration if a query or problem occurred. The recording of administration for oral medicines was good. There were no significant gaps on the MARs indicating that these medicines are mostly given as intended. However on the residential unit complete records of Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 13 administration of external medicines such as creams were not always made. For example one person was prescribed a pain relieving cream at a dose of three times a day but only twice a day had been recorded as administered. This meant it was difficult to see from the information on the MAR if it had been administered as prescribed. Medication was found in the fridge on the nursing unit that should not be stored at these temperatures. This means that the person receiving this medication may find it too cold and uncomfortable. There is a good system for the ordering of monthly prescriptions. The prescriptions are sent to the home before going to the pharmacy. This is an example of good practice as it is an opportunity to check if any new medicines or dose changes are included and any problems with prescriptions can be addressed at this point rather than after the supply has been made. The date of opening on medicines with limited use once opened is recorded. This is good practice as it reduces the risk of people receiving medication that may have deteriorated and may not be safe to use. Acre Green Nursing Home DS0000001317.V372632.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. Peoples’ social expectations and personal preferences are met and there is a range of activities on offer for them including links with the local community. They are able to exercise choice in their lifestyles so they can be as independent as they can. People living at the home are provided with a varied and nutritious diet so they can eat healthily. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has appointed a new activities person. Each unit has it own activities programme and there are also one to one activities with people who need to be nursed in bed or in their rooms. New activities have been introduced to stimulate residents like a baking group and Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 15 quiz group. The home has access to a mini bus which is used regularly to provide trips out. A number of people regularly go out in the local community on their own. This helps them to stay independent as possible and still feel that they are part of the community. Two people go for their own morning papers, one attends the local day centre twice weekly, one goes shopping in Leeds Market every Saturday and one goes to his local Working Men’s club/pub twice weekly. People are encouraged to maintain contact with their local community and there are no restrictions on friends and visitors visiting the home. All of those spoken with said that they felt welcome. A regular flow of visitors could be seen throughout the time spent at the home. Regular meeting with residents, and relatives are held to discuss home life including food and menus, activities, future refurbishment etc. The home has links with local schools and churches, and a communion service is held each month for those people wanting to take part. The current cycle of menus seen showed there was choice, variety and good nutritional value. The home now uses a system called ‘Nutmeg’ adopted by Southern Cross so that the nutritional value of each meal can be calculated. Peoples’ special dietary needs are catered for including diabetic, soft and puree. The dining rooms were well set and the people spoken with enjoyed their meal and said the food was generally good. Staff also felt the food was consistently good. People clearly enjoy a lot of choice in their daily routines, and those spoken with said they are able to get up and go to bed when they wish, spend time on their own or join in activities or chat with friends or simply watch what was going on. They looked well cared for, were happy and the relationships with each other and the staff were relaxed. All people have been assessed to have a key to their bedrooms and those who are able to lock and open their bedroom door independently have a care plan and risk assessment. Acre Green Nursing Home DS0000001317.V372632.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. 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 action will be taken when necessary. There are adult protection procedures that staff are aware of through training, so people can be assured that they can feel safe because staff know what to do. EVIDENCE: The home aims to deal with situations as they occur, and encourages families to discuss any area of concern with the nurse or manager at the outset. In the conversations with people during the day this was clearly the normal way of doing things. People felt comfortable about raising things and said that they were listened to and actions were taken. The home has a clear complaints procedure that is displayed in the entrance hall and also in the service user guide. A file of complaints is kept and this was seen. Where formal complaints have been made, these have been investigated under the appropriate procedures and properly documented. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 17 Protection of Vulnerable Adults training is ongoing for staff and is mandatory training. This is also discussed at staff meetings and in individual supervision sessions. Other checks made on recruitment, safekeeping all met required standards. medication and money held for Acre Green Nursing Home DS0000001317.V372632.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 and 26. People who use the service experience good quality outcomes in this area. People living at the home live in a clean, comfortable and safe environment that is properly maintained and regularly improved. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The tour of the premises found things clean, well maintained, and odour free with the gardens tidy and providing access for residents to enjoy the outdoors. The courtyard area is accessible through the ground floor lounge and is secure, this allows the service users to use the courtyard and lounge freely and safely. Bedrooms were comfortable and personalised. People and their Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 19 families are encouraged to bring personal items such as photos, pictures, ornaments and small items of furniture to make them feel settled and ‘at home’. All corridor areas have now been redecorated in soft light colours and staff have been doing painting and artwork to create interest and further ‘soften’ the environment. There is some artwork from children from the local nursery, a forties section created, an indoor garden section and a food and drinks section on the nursing unit. The large dining area on the residential unit is used for entertainments and baking activities. Another smaller lounge area that was little used is being converted into an activities room which will include a snooker table. The hairdressing room has been re furbished. There is a programme of providing each bedroom door with brass doorknocker, letterbox and a nameplate. The emergency call system was checked during the tour and this was working satisfactorily. People were asked if staff respond quickly and said they did. A lot of different equipment was available throughout the home to aid moving and handling and help people maintain independence. The AQAA confirmed that all regulatory health and safety monitoring checks were up to date at the time of the inspection. Staff were seen to be wearing protective clothing to avoid the risk of cross infection. The laundry is well equipped. Acre Green Nursing Home DS0000001317.V372632.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. People living in the home are cared for by committed staff who are properly recruited, trained and qualified for the job. We have made this judgement using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection visit the manager had not been in post long and was challenging some staff practices including staff sickness. It is clear that there has been resistance by some staff to being managed and directed. The last year has not been easy with some staff turnover and difficulties with recruitment. From the accounts of staff there have been times when they felt they had been working below the numbers they should. Nevertheless they also reported an improvement in moral, stability in the team and working together as a team. They said there had been recent improvements because of recruitment that had been taking place and felt these had been good appointments. As a matter of record keeping (Standard 37) it was difficult to check the accuracy of the numbers of staff on duty because the duty rotas did not always show where agency staff had been used or where home staff had covered an absence. Duty rotas must accurately reflect which staff are on Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 21 duty so the home can fully evidence it is providing enough staff to meet the needs of the people living at the home. The home is working towards targets for the number of care staff who should have a National Vocational Qualification (NVQ). The training matrix seen shows what training individual staff have received. New and existing staff talked about their induction and ongoing training. The recruitment files for the three most recently appointed staff were checked. These showed that recruitment was thorough with the required referencing and vetting being done. All staff had application forms, interview check lists a contract, two references, one being from the last employer, and checks had been made with the Criminal Records Bureau. This makes sure that people are protected from staff who may not be suitable to work in the care industry. From what was seen during the day, there are good relationships, people looked well cared for, were happy and there was a good atmosphere in the home. Relationships were warm and there was some friendly banter from time to time. Visitors also appeared to be enjoying their time in the home and had good relaxed relationships with staff. Acre Green Nursing Home DS0000001317.V372632.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, 33, 35 and 38. People who use the service experience good quality outcomes in this area. The home is well managed and the opinions and interests of the people are central to the way the home is run. Safety checks and systems of communication make sure that the home is a safe place to live. We have made this judgment using available evidence including a visit to this service. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is experienced and qualified and is currently going through the process of formal registration with CSCI. Although not a qualified nurse, she has access to clinical support through the company. From the conversations with people, visitors and staff she is considered approachable, encourages new ideas and has high standards of care. Staff feel that they have a clear understanding of what the manager expects from them. There are regular staff meetings, individual supervision sessions and staff feel supported. The home sends out satisfaction survey on an annual basis. There are quarterly meetings with relatives, representatives and people living at the home where people are invited to make suggestions on what could be improved. Some improvements to the environment have resulted as a direct consequence of suggestions made. Comment cards are available in the reception area and can be sent to the Company’s Operations Director. The home manager holds weekly surgeries every Thursday from 9am to 6pm, which is advertised in the reception area. A new development has been courtesy calls made by key workers to families or representatives each month to see if the home can help or assist with any concerns and check how they are feeling about the care being provided. The company makes its own quality checks that make sure that the home is compliant with legislation and National Minimum Standards and if not, what actions need to be taken. Part of this is for the operations manager to visit monthly. She writes a report on the conduct of the home reporting on people she has spoken with including relatives and staff, records and audits that have been made, complaints, staffing and a tour of the premises. A copy of the report is sent to us each month and this helps us monitor what is going on. The home holds some people’s personal money for safekeeping. The manager described and demonstrated the systems, procedures and practices for making sure this is properly accounted for and is safe. One person’s records were checked and receipts for all purchases supported the record. People can be assured their money is well looked after and accounted for. The home is required to keep records of staff duty rotas but these did not accurately reflect the numbers of staff on duty. Staff were seen to be wearing appropriate protective clothing to prevent cross infection and safety checks are made of the facilities and equipment to make sure the home is a safe place to live. The housekeeper and team do well to make sure the home is clean and free from unpleasant odours. Staff are trained in safe working practices and are up dated regularly. Some records of Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 24 safety checks were seen and found to be up to date. Accident records were also checked and were properly recorded and are audited by the manager to check if risks can be reduced. The AQAA confirmed that equipment and facilities are checked regularly to make sure it is in good and safe working order. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 25 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 26 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) Timescale for action Accurate records must be kept of 30/11/08 the administration of all medicines. This will make sure that there is information available to know how people have received their medication. Duty rotas must accurately 30/11/08 reflect which staff are actually on duty. The home can then fully evidence it is providing enough staff to meet the needs of the people living at the home. Requirement 2. OP37 17(2) 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 OP9 Good Practice Recommendations Only medication requiring storage at cold temperatures should be kept in the fridge. This makes sure medication is safe to administer. Acre Green Nursing Home DS0000001317.V372632.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Acre Green Nursing Home DS0000001317.V372632.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. 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