Inspection on 22/04/08 for 1-2 Orchard Mews

This inspection was carried out on 22nd April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-2 Orchard Mews 03/05/07

1-2 Orchard Mews 07/02/07

1-2 Orchard Mews 14/10/05

1-2 Orchard Mews 20/05/05

1-2 Orchard Mews 14/01/05

1-2 Orchard Mews 08/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 1-2 Orchard Mews Bakers Drove Rownhams Southampton SO16 8AD Lead Inspector Chris Johnson Unannounced Inspection 22nd April 2008 11:45 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 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 1-2 Orchard Mews DS0000059159.V361205.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 Adults 18-65. 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. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1-2 Orchard Mews Address Bakers Drove Rownhams Southampton SO16 8AD 023 8073 9076 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) www.choicesupport.org.uk Choice Support Post Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies service only: Care home only - (PC) to service users of the following gender: Either Whose primary needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) The maximum number of service users to be accommodated is 6. Date of last inspection 3rd May 2007 Brief Description of the Service: 1-2 Orchard Mews consists of two purpose built bungalows with through access via the office. Service users have learning disabilities and those living in bungalow 1 require a high level of physical support, have communication difficulties, and are wheelchair users. The occupants of bungalow 2 have greater communication skills and are more physically able. One staff team operates throughout the home, although the service users tend to keep their own area of the home. The fees for living in this home are £4407.40 per month. People pay an additional fee of £324.25 per month towards the cost of day care activities. 1-2 Orchard Mews DS0000059159.V361205.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 1 star. This means the people who use this service experience adequate quality outcomes. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards, compliance with regulations, previous requirements and to assess what the outcomes are for people who live at his home. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out over one day on 22nd April 08 whereby we looked at all key standards. We were informed in February 2008 that the registered manager is no longer employed by the organisation. The registered manager had been absent from the home for several months prior to this. During this time an acting manager has managed the home. All regulatory activity since the last inspection was reviewed and taken into account including any notifications sent to the Commission for Social Care. The acting manager completed an Annual Quality Assurance Assessment (AQAA) prior to the annual service review. Surveys were sent to all six people living at the home, fifteen members of staff, three healthcare professionals and two care managers. Relative surveys were sent to the acting manager for him to distribute. At the time of writing this report we had received completed surveys from everyone living at the home, six members of staff and one relative. During this visit we looked at the physical environment including, people’s bedrooms and all communal areas of the home. Staff and care records were inspected. Some members of staff were spoken with and others were observed during their day-to-day interactions with those living at the home. We examined records, policies and procedures. We spoke with people who live at the home. Due to the communication needs of the people living at the home we were not able to hold discussions with them. However we did talk to people briefly, interact with them and spend time observing the care being given to them. The acting manager was present on during the visit to answer questions and discuss issues. Verbal feedback was provided at the end of the inspection. 1-2 Orchard Mews DS0000059159.V361205.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: Generally medication is well managed. However some work is required to demonstrate that safe practice is maintained at all times. Whilst at a local level within the home there are procedures in place to protect people such as, staff training in adult protection and the management of peoples’ money. We could not determine how peoples’ finances are being managed centrally and that they were therefore fully protected. This issue has been raised at previous inspections. Some repairs are needed in the kitchens and the home would benefit from a refurbishment of the kitchens. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 7 The system of recording recruitment practices does not demonstrate that a thorough process is followed to maintain the safety of people who live in the home. For instance the home could not demonstrate that newly recruited members of staff had undergone ‘Protection of Vulnerable Adults’ checks. The home cannot demonstrate that it has fully complied with previous requirements. Both of the outstanding requirements relate to the protection of those living at the home and this means that we have concerns about the effectiveness of the management of the home. 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. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are fully assessed prior to admission so that the individual and the home can be sure that the home is right for them and will meet the person’s needs. EVIDENCE: There had not been any new admissions to the home since the previous inspection. At the time of this visit the home had a vacancy and the home was in the process of accepting referrals as part of the admission procedure. From discussion with the acting manager we found that the home was following an appropriate assessment procedure as had been found at the last inspection of the home. This included the opportunity for prospective residents to visit the home prior to moving in. The AQAA stated that, ‘Choice support has a comprehensive admission procedure this ensures peoples needs are fully assessed prior to admission, so that the individual and the home can be sure that the placement is appropriate and will meet the individuals needs. This would include completing a referral form, moving in checklist and a needs assessment. This process would involve visits at various times to meet other service users and to establish that needs can be met’. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 10 This was substantiated by responses from people living at the home in the completed surveys. Whereby all answered that they had been asked if they wanted to move into the home and that they were given sufficient information on which to base their choice. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are kept under regular review and recorded in detailed and personalised plans of care that promote independence. EVIDENCE: During the visit to the home we examined three peoples’ care plans. These were comprehensive and were integrated with risk assessments and risk management plans. Initial planning meetings are held with the individual, their friends, family and advocates as appropriate to assist with gaining input with regard to peoples’ personal preferences, choices and other needs. Care plans are reviewed at regular intervals or as and when a change in a persons’ support needs occurs. The care plans looked at were written in the first-person and were personcentred. Care plans demonstrated that peoples’ independence is promoted and highlighted each person’s abilities as well as their needs. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 12 Peoples’ personal care and daily support needs were clearly identified and care plans provided step-by-step instructions regarding the level and type of support needed with various care needs. All care plans looked at provided evidence that people had been consulted and involved in formulating their plan and on the day of the visit one person attended a review meeting with staff. Sections headings within the care plans used terms such as ‘How is my support given’ and ‘why I need support’ The health and personal care section of the plans demonstrated in particular that care is provided in a way that respected personal choice and preferences. We saw that people are able to take risks as part of their everyday lives and that plans were in place to manage these appropriately. Care plans offered guidance for staff for anyone who may become anxious or exhibit challenging behaviour and described what approaches to use how to offer reassurance and key terms to use. Alongside this each person had communication profiles stating how to offer choices for that person and how they would respond (how they communicate their choices). Staff had all signed to confirm that they had read each care plan and staff spoken with confirmed that they had access to care plans. The results of staff surveys were that four staff responded that they were ‘always’ given up to date information about the needs of the people that they supported, one responded ‘usually’ and one ‘sometimes’. The one relative survey returned told us that they considered that the home ‘always’ met the needs of their relative and provided the support and care that they expected. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are able to make choices about their life style, and are supported to develop life skills. People are supported to engage in activities and to keep in contact with friends and family. EVIDENCE: Information recorded in the AQAA listed a variety of educational and leisure activities available to people at the home. These included; college courses, attending social and community-based activities such as line dancing, cooking, keep fit and a women’s’ group. When we arrived at the home two people were out with staff and another was at day services. The acting manager said that people accessed a variety of 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 14 different centres including a local school. One person has been assisted to have an activities group come into the home for one to one music and singing sessions on a weekly basis. Staff have recently undertaken ‘skills teaching training’ in order to support people in acquiring new skills. The acting manager explained that this was due to be implemented in the near future. We confirmed through information recorded in care plans and other records held at the home that people do engage in a variety of activities of their own choosing. The one relative survey returned told us that they considered that the home supported people to live the way they choose, kept them up to date with important issues effecting their relative and helped their relative to keep in touch with them. Evidence was seen that people are offered a balanced menu. Meals can be chosen based on individual likes and healthcare needs. People who use the service have very specific eating and drinking guidelines in place to ensure their safety and wellbeing is maintained and these have been completed with input from the specialist healthcare team. We observed staff supporting individuals at lunchtime, in a relaxed and unhurried setting. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are fully supported with their healthcare needs and have access to a range of specialist healthcare support. People receive personal support in the way they prefer and according to their needs. Generally medication is well managed. However some work is required to demonstrate that safe practice is maintained at all times. EVIDENCE: The healthcare records for three people were examined. Records demonstrated that the home liaises with outside professionals and other agencies as appropriate and that people had access to a range of healthcare services such as GP’s, dieticians, speech and language therapists, community learning disability nurses and psychiatrists. We saw evidence that peoples’ healthcare support needs are monitored and that people are supported to attend appointments as necessary. Within the care plans each person had an individual health support plan and these had been signed by their GP. Support with individual needs such as 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 16 those associated with epilepsy were thoroughly documented and provided clear guidelines and instructions for staff to follow. One health support plan looked at was in pictorial format and described how the person expressed different emotions and health conditions. Staff spoken with understood the principles of upholding the privacy and dignity of people who use the service when giving personal care and support and this was addressed within care plans. We also saw that people could exercise choice and that their preferences regarding their personal support needs had been taken into consideration and were respected. An example of this being that one person had requested that assistance with personal care should only be provided by a female. The medication administration records were checked for two people during the visit. It was noted that there were gaps on one persons’ medication administration recording chart (MAR). The acting manager explained this was due to the person being at day services at these times and therefore not able to take the prescribed dose of three times a day and therefore on occasions one dose had not been administered. There was not however any written record of this on the MAR and the acting manager was unsure whether a missed dose would have any negative effect or whether the dose could be taken at a different time of the day. No further errors or concerns were found when looking at the MAR for the second person and from examination of records it was evident that staff were following correct administration recording with the exception of coding when someone missed a dose. The home takes delivery of medication on a weekly basis and most of the prescribed medication is packaged in a monitored dosage system pre-prepared by the pharmacist. The MAR charts are however issued by the pharmacist for a three-week period. This made it difficult to tally and also meant that the amount of medication detailed on the pre-printed MAR as being received into the home was incorrect. The acting manager agreed to discuss this with the pharmacist. The system for recording the receipt of medicines into the home not in the monitored dosage system was more robust and a record of medication returned to the pharmacist for disposal was clearly documented and two staff members and the pharmacist had signed these records. Evidence was seen to demonstrate that staff undergo training before being able to administer any medication and medication was stored safely and correctly. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Satisfactory systems are in place for people to address any concerns or complaints that they may have. Whilst at a local level within the home there are procedures in place to protect people, we could not determine how peoples’ finances are being managed centrally and that they were fully protected. EVIDENCE: The training records for staff confirmed that training in adult protection takes place and staff spoken with or who returned a survey all knew the procedures for reporting any concerns. One person commented, “It is easy to put in a complaint and there are plenty of different levels of management to talk to e.g. assistant, team manager and service manager”. In discussion with the acting manager we were told that people living at the home had access to an independent advocacy service and that they would be contacted should someone living at the home have a complaint and needed support. Examination of the home’s complaints log and records from the organisations head office provided evidence that concerns and complaints had been dealt with and actioned appropriately. This was substantiated by the response received from the relative survey. The home has the facility to looks after peoples’ money. We looked at the procedures for looking after peoples’ money and checked the records for two 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 18 people. All transactions had been recorded and receipted as per the homes’ policy with regular checks carried out by the acting manager. Larger amounts of money belonging to people are held centrally and small amounts of money are requested and sent by the organisation, which is then held in the home. A requirement was made following the inspection of 7th February 2007 and then repeated at the last inspection that the home needed to demonstrate how the centrally held money was being managed and that they needed to confirm that the money was not being held in an account used for the running of the business and that people were receiving interest on the money they had deposited. In response to the last report Choice Support told us that were making arrangements for peoples’ money to be held in individual accounts. We received confirmation that Choice Support had allocated interest to everyone who they held money for in October 2007. Confirmation has not been received that the money has been put into peoples’ individual accounts. We could not find any evidence at this inspection that this had been done. We will be writing to the provider to seek further clarification on this matter. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 People who use the 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 home is well furnished, comfortable and homely. The home is clean and tidy and good standards of hygiene are maintained throughout the home. Some repairs are needed in the kitchens and the home would benefit from a refurbishment of the kitchens. EVIDENCE: During the visit to the home we saw all communal areas and a selection of peoples’ bedrooms. Peoples’ bedrooms reflected their individual tastes and needs with specialist equipment such as hoists in place where necessary. People had been able to personalise their rooms with pictures, belongings, televisions and audio equipment. People were observed to access and spend time in their rooms as they chose. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 20 The general upkeep of the building is maintained and the furnishings and décor are replaced as necessary. The AQAA identified the improvements that had been made and that were planned for the future. These included a new lounge carpet that had been chosen by people living at the home and new lounge chairs. In the last year three people have had their bedrooms redecorated to the colour and style of their choice. The AQAA states that the remaining two people are planning to do the same this year. Some of the planned improvements identified in the AQAA had been made by the time we visited the home. A new sofa had been purchased and the home had secured an agreement from the housing association that owns the building to redecorate the lounges. Colour charts had been obtained and people living at the home were in the process of choosing and deciding upon colour schemes. On the day of the visit the home was found to be clean and tidy and homely. From observation people were relaxed and at home in the environment. We have reported at the last two inspections that the kitchens are showing signs of age. Whilst we cannot say that at present the condition of the kitchens is such that they present a health and safety issue they do require some attention. The home will need to monitor this and take action as necessary. Repairs have been made to the units on several occasions and further repairs are needed. The material used to construct the units is not robust and will not withstand continual repairs. The home has told us that this has been raised as part of the service development and improvement plan in negotiation with the housing association that own the building, however they have been told that kitchens will not be replaced until 2012. The provider will need to take action to keep the kitchens in a good and safe state of repair or replace as necessary. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are well trained and are provided with appropriate support and supervision. They are employed in sufficient numbers to meet the needs of people living at the home. The system of recording recruitment practices does not demonstrate that a thorough process is followed to maintain the safety of people who live in the home. EVIDENCE: During the visit to the home staff rotas were examined. These confirmed the rota to be a true reflection of actual staffing levels. Staffing levels remain constant and are maintained at the same level as at previous inspections. Rotas are planned in advance and it was seen that they had been planned for the following four weeks. The rotas also provided evidence that arrangements were in place to provide cover when staff are absent. The home has had a vacancy for a waking night worker for some time and has used agency staff to cover this post. From examination of the rota and from discussion with the acting manager we saw 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 22 that when used agency staff are regularly the same people and this provides consistency. The home had recently recruited a new night worker and at the time of the visit they were in the process of completing all pre- employment checks such as obtaining references and carrying out criminal records checks before allowing the applicant to start work at the home. The results of staff surveys were that all responded that they had been through a thorough recruitment process. One person commented, “Choice requires two references and a CRB before you are allowed to start”. We have made requirements on four occasions regarding maintaining recruitment records. Choice Support has an agreement with the Commission for Social Care Inspection that staff records will be held at their head office. However as part of this agreement they are required to hold evidence within the home that certain checks have been completed including the dates of when these were obtained. The organisation wrote to us following the last inspection stating that they would be recording this on a proforma provided by the Commission for Social Care Inspection. We found at this inspection when looking at the recruitment files of newly appointed staff who had commenced work at the home that this information was not held at the home as per the agreement. From examination of staff files, discussion with staff and feedback from surveys it was evident that the home provides training and development opportunities relevant to their work. The AQAA reported that eight of the twelve permanent staff have achieved an NVQ level 2 or above and that one staff member is currently undertaking the course. When completed this will take the number of staff trained to this level to 75 . We saw evidence that new staff had undertaken ‘skills for care’ linked induction training and a basic induction into the home and a corporate induction. The training calendar for forthcoming months showed that staff are booked to do a variety of training and training updates such as protection of vulnerable adults training, fire and moving and handling. All staff contacted confirmed that they were given training that was relevant to their role, helped them to understand and meet the individual needs of people living at the home and that kept them up to date with new ways of working. 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home cannot demonstrate that it has fully complied with previous requirements. Both of the outstanding requirements relate to the protection of those living at the home and this means that we have concerns about the effectiveness of the management of the home. The home is generally well maintained and equipment is serviced to keep everyone safe. EVIDENCE: 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 24 We were informed in February 2008 that the registered manager is no longer employed by the organisation. The registered manager had been absent from the home for several months prior to this. During this time an acting manager has managed the home. Choice Support has kept us informed of the management arrangements during this period. The acting manager has worked at the home for about two and a half years. Choice Support will now need to appoint a permanent manager and make arrangements to submit an application for registration. We are concerned regarding the lack of action taken to fully address the outstanding requirements. Some areas highlighted in this and previous reports regarding staff recruitment records and the management of monies belonging to people who use the service, are directly related to the management of the home and have yet to be sufficiently addressed to demonstrate that the home is managed effectively. This inspection has also raised an additional requirement regarding the safe management of peoples’ medication. Regarding the above issues the organisation will need to look at reviewing the service as part of the quality assurance process. We did find that there had been some ongoing improvements such as the care planning system, risk management and review system and the acting manager has overseen and ensured that these improvements have continued. Data recorded in the AQAA told us that policies and procedures are kept under regular review and examination of a sample of these confirmed this. The AQAA also gave details and evidence that maintenance checks, tests and servicing of equipment are carried out on regular basis evidence seen during the visit substantiated this. Examination of the fire logbook demonstrated that regular and thorough testing and servicing of the home’s fire detection and fire-fighting equipment and other appliances had been carried out as appropriate. 1-2 Orchard Mews DS0000059159.V361205.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13 (2) Requirement Timescale for action 15/07/08 2. 3 YA23 YA34 20(1) 19 Schedule 2 All medication must be administered as prescribed. Administration records must be accurately maintained. All monies belonging to each 15/07/08 service user must be held in individual accounts. Where staff records are held 15/07/08 centrally the home must keep written evidence within the home that all necessary recruitment checks have been undertaken in the form of a proforma as previously agreed by the Commission for Social Care Inspection. 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 YA20 Good Practice Recommendations It is advised that you obtain a copy of the most recent guidelines from the Royal Pharmaceutical Society of Great Britain. DS0000059159.V361205.R01.S.doc Version 5.2 Page 27 1-2 Orchard Mews 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 1-2 Orchard Mews DS0000059159.V361205.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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