Inspection on 07/02/07 for 1-2 Orchard Mews

This inspection was carried out on 7th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-2 Orchard Mews 22/04/08

1-2 Orchard Mews 03/05/07

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 08/07/2008.

CARE HOME ADULTS 18-65 1-2 Orchard Mews Bakers Drove Rownhams Southampton SO16 8AD Lead Inspector John Vaughan Unannounced Inspection 7 February 2007 10:00 th 1-2 Orchard Mews DS0000059159.V319142.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.V319142.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.V319142.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 To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 2005 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 £1040 per week. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met with service users, staff members and the manager during the visit to the home, which took place over one day. During the visit the inspector spent time with service users, observed service users and staff, sampled records, had individual meetings with staff and toured the home assisted by the manager, staff and service users. In preparation for this visit the inspector also examined information obtained about the service including the pre-inspection questionnaire completed by the manager, incident reports, regulation 26 reports and the most recent inspection reports on the home. What the service does well: What has improved since the last inspection? The garden in the front of the home has been developed to make it a more attractive space. The manager has continued work on developing and improving the care planning and record management in the home. 1-2 Orchard Mews DS0000059159.V319142.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. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 7 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.V319142.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service has a process of assessment and documenting service user’s needs however the current practice in the home does not demonstrate that this process is implemented effectively. The recent practice of the home admitting a service user outside of their registration categories does not demonstrate that the service adheres to a satisfactory admission process. EVIDENCE: The inspector examined a sample of three service users files including the information for a service user who moved into the home last month. The new service user’s assessment information has not been put in place yet. The inspector read information on the service user’s assessed needs and how to meet these needs in a care plan provided from the service user’s previous home. The home could not provide any evidence of an assessment completed by the care manager and the manager stated that they have not been in a 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 9 position to put a plan in place, they completed a risk profile but this could not be located during the visit. The manager and staff explained that the service user was visiting the home as part of their orientation programme and on one of these visits they turned up with all of their belongings and moved in. This had not been planned however their previous placement closed on the same day and they agreed to accept the service user. The manager stated that they intend to put a full assessment and care plan in place. The inspector noted that at the time of the visit the team were coming to terms with this loss of a service user that had passed away very recently. The manager was advised that they must completed a full assessment of the persons needs and develop are service user’s plan in response to these needs. Two other plans examined by the inspector contained information on service user’s needs and more detailed support plans to meet these needs demonstrating that the home has carried out assessments of the individuals and responded to their needs. During the course of examining the records of the newest service user in the home the inspector found evidence that this person is over the age limit currently permitted for this service. This is a serious concern that will require action by the registered provider and will be addressed separately from this report. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made in the approaches of the home to documenting and responding to the assessed needs of service users however more work is still needed to demonstrate that a consistent and effective care planning process is in place. EVIDENCE: The new service users plan does not exist in a format created by the home however vital information and care plans are being used from the person’s previous placement. This includes a strategy for supporting the individual during an epileptic seizure. The strategy calls for the administration of medication that requires an invasive procedure. This cannot be carried out at present, as staff members have not received the training or authorisation to do this. The manager is 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 11 aware of this however they will need to update the guidelines to make this clearer. Two other service users require medication via an invasive route and the inspector was able to confirm the involvement of the district nurse and specialist healthcare team in training staff for both procedures however there are no documented agreements in place to authorise staff to carry out these procedures. The manager has written detailed guidelines but the district nurse, general practitioner or staff have not signed these. With the exception of the new service user’s documentation the two other plans examined by the inspector contained a good level of information and strategies to support the individual service users. Support plans included personal care, healthcare, mobility, eating and drinking and cross gender personal care. A section within the support plans deals with managing risk with an assessment of the activity and control measures to minimise the risk of harm to the service user. One plan has the new version of risk assessment being introduced into the home this is a more accessible format which encourages the involvement of the service user and have a more service user centred assessment. The plans seen are all in need of updating and reviewing as they have been in place for over a year in some cases. The inspector sat with and observed service users during the visit to the home the staff provided support in sensitive and valuing ways. Staff spoke to service users informing them of what they were doing and offered choices to the individual throughout the day. Service users moved freely around the home and for those people who require assistance getting around the home they were asked were they would like to be. The manager discussed how they are introducing new person centred plans to develop the involvement of service users in making choices about their support. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 12 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, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities that they enjoy enhanced by contact with families and support to maintain important relationships. Service users have a health and balanced diet that has been geared towards their individual needs. EVIDENCE: The home produces an activity plan to include each of the service users. The inspector also examined a record that the staff keep to document the activities service users take part in and their responses to the activity. This, the inspector felt was very valuable information however there is no mechanism at present to evaluate these observations. This was discussed with the deputy manager who agreed to look at using this information constructively. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 13 From this information the inspector confirmed that service users take part in activities including trips to clubs, shopping, cooking, keep fit, day service groups, Internet research at a day centre and a group of service users went to see a musical. Activities for a new service user are limited at present as the staff get to know the person and their likes and dislikes. The introduction of clear support planning strategies will help to develop the individual’s involvement in activities. Service user’s plans contained information on important relationships in their lives. Families visit regularly and the staff stated that there are no restrictions on visiting the home. One service user is supported to maintain a long-term relationship. The inspector saw evidence of a balanced menu plan for service users. Meals are chosen based on service users likes and healthcare needs. One person is being supported to take more foods that contain beneficial vitamins and iron to improve some identified health issues. Service users have very specific eating and drinking guidelines in place to ensure their safety and well-being is maintained and these have been completed with input from the specialist healthcare team. The inspector sat with a service user during lunch and observed staff supporting the individual in a very sensitive and effective manner. The meal was unhurried and lunch was presented in a pleasing way with the essential aides required by the service user to be independent in eating their meal. The staff said that it is the policy of the home to sit and eat the same meals as service users in a group however the current method of obtaining monies from the head office for food has meant that at times insufficient funds are available to provide meals for all and service users are a priority. This means that the home’s policy of eating the same meals as service users together with service users cannot be followed. It was unclear if service users could have extra or seconds if the amount of food is limited. The inspector did not see any evidence of this at the time of his visit and the cupboards and fridge were well stocked. The manager was advised to keep this under review. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides support for service users to access health Care professionals to meet their needs. Personal support is given in a way that respects the privacy and dignity of the individual. The homes practices in the administration and recording of medication generally meet service users needs however some work is required to demonstrate that safe practice is maintained at all times. EVIDENCE: Each person is registered with a general practitioner and records are kept of all appointments. Evidence was seen to confirm that service users are supported to attend medical appointments and maintain their health needs. Files examined by the inspector contained support plans to meet the healthcare needs of service users. Medication records were examined and these were completed accurately. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 15 Medication is stored securely in a suitable medication cupboard that has been fitted since the last inspection. This has improved the storage and accessibility in the home. Staff have undertaken training and assessment before they can administer medication to service users. The inspector noted that a new service user’s medication is yet to be transferred into the monitored dosage system used in the home. A “dosett” box has been used to dispense medication from the original packages that came with the individual into the sectional containers in the dosett box. The manager was advised that this is secondary dispensing and increases the risk of a mistake in the administration of medication. The manager was advised to stop this practice. A service user’s support plan covering medication included instructions to use jam and honey. The manager explained that this was only used as a medium To help the service user swallow the tablets and it was not advising covert medication administration. The manager was advised to clarify this in the support plan. At the last inspection the home was required to obtain authorisation for the use of invasive methods for administering medication. This is not fully in place and the manager was again required to obtain this permission from service user’s general practitioners. This will ensure that the training and practices have been agreed with the service users GP. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to respond to the concerns of service users and their representatives however the lack of information in the home means that the inspector cannot determine how effective these systems are. The inspector could not determine how service user’s monies are being managed from the information he could see in the home. EVIDENCE: At the last inspection of the service the home was required to complete and keep a log of all complaints in the home. The inspector spoke to the manager about this issue and he was told that a log was put in place and no complaints have been received since the last visit. The manager could not locate the file that he has set up and he also stated that the previous complaints that have been raised have not been recorded in this log. The inspector advised the manager that they must keep an accurate record that is accessible for inspection and if confidential information cannot be entered into the record the record must be referenced to where this information is stored in the home. The training records for staff confirmed that training in adult protection takes place and staff who spoke to the inspector were clear in their roles and responsibilities when keeping service users safe. A recent staff meeting 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 17 discussed attitudes and zero tolerance to any forms of abuse or poor treatment of service users. The inspector discussed the current arrangements for managing service user’s monies with the manager and deputy manager. Service user’s money is held centrally and small amounts of money are requested and sent by the organisation, which is then held in the home. The inspector saw evidence to confirm that monies spent for service users is recorded and receipted in the home. The manager provided a printout sent from the head office but could not explain how this account is held. The print out did not include information on how interest was applied to the monies as some service users have considerable sums being held by Choice Support. None of the service users are supported to use a bank accounts and the manager was unsure if this would change. The inspector is unclear as to the benefits of such a remote system and why more able service users are not supported to take more control of their accounts. The placement fees do not include food and service users are required to contribute money on a weekly basis. The manager explained that the placement fee has been reduced by the amount paid for food and service users receive their full personal allowance. This is documented in the statement of purpose and service user’s terms and conditions. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 18 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, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a comfortable home enhanced by individually personalised private rooms. The overall service would benefit from a refurbishment and repair of the kitchens. EVIDENCE: The inspector toured the home assisted by the manager. The home is clean, tidy and free from any unpleasant smells. Service users let the inspector view their private rooms. These rooms were decorated to their personal tastes with pictures, posters and personal items. Both rooms had good levels of equipment televisions, DVD, CD players and radios. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 19 The home is generally well maintained and had good furniture in the communal areas. The kitchens are showing signs of age and staff agreed that they are worn out. Running repairs to cupboards are evident and in bungalow one the majority of handles are broken including the over door handle which is burnt and broken. The area needs to have attention to improve the part of the home. The manager stated that this has been raised as part of the service development and improvement plan and they are negotiating with the housing association for a replacement however they have been told this will not be until 2012. The home has two separate gardens with seating for service users who enjoy sitting out in the warmer weather the fence is down on bungalow two and they are waiting for the housing association to fix this. A lot of work has taken place to improve the garden to the front of the home and this looks very neat and tidy. Each bungalow has a utility room containing the laundry facilities and the manager stated that these machines continue to meet the services needs. The utility room door automatic closures have been repaired and were not propped open during the visit. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 20 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, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a staff team who have been well trained and supervised to meet their needs however the current recruitment practices in the home do not demonstrate that a thorough process is followed to maintain the safety of service users. EVIDENCE: The inspector examined the records for five staff members who have been employed since the last inspection of the service including the recruitment, training records and staffing rota. The inspector confirmed that a minimum of two staff are on duty on each side of the home. Each staff did have a recruitment file which is an improvement since the last inspection however three of these records were found to be incomplete. One file did not have evidence of an application form being completed and there were no references to support this appointment. Another file did not have any references and no evidence that the individual had undertaken a Criminal 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 21 Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks, there was no evidence that this person had provided proof of identity. A third file had a checks but the reference for the persons last position in care had not been taken up. The two other files seen by the inspector had all of the relevant information in place. Staff training records were examined this provided evidence to confirm that staff are undertaking training and development relevant to their work. Staff have undertaken an induction and foundation. Five staff have obtained a National Vocational Award (NVQ) at level 3. New staff are complete their induction and foundation training before being put forward for the NVQ award. A training programme ensures that staff undertake training in moving and handling, fire safety, food hygiene, health and safety and first aid. Staff members have also attended training in dementia to support a service user whose needs changed and staff received training in bereavement do prepare for this person passing away. Additional training is also provided for staff including communication, epilepsy, autism, diabetes, mental health, care of medicines and skills teaching. Discussions with staff members confirmed that they feel well supported through formal and informal supervision and that they are encouraged to develop their skills and abilities. Staff confirmed that they have a programme of induction into the home and are encouraged to develop their skills through training. Team meetings take place and staff reported that the communication is good in the home. 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a service, which is managed in a generally more effective manner however some areas need to be addressed to fully demonstrate the effectiveness of this management. The organisation has systems to ensure the views of service users and their representatives influence the running of the home. There is no evidence that these systems have had any impact on the service and the effectiveness of these systems will need to be assessed at future inspections. The home is generally well maintained and equipment is serviced to keep everyone safe. EVIDENCE: 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 23 The home does not have a registered manager however the current manager confirmed that he is now staying in the service and has made an application to the commission to be registered. A new deputy manager has also been recruited and appointed since the last visit to the home. It is important that the stability of the management team is maintained to ensure that improvements continue to be made to the service. Some areas highlighted in this report such as staff recruitment records, service users assessments and the admission out of category are directly related to the management of the home and will need to be addressed to demonstrate that the home is managed effectively. The inspector saw evidence of improvement in the organisation of information, care planning, risk assessment processes and the positive staff attitude that can be attributed to the current management of the home. The organisation have developed a quality assurance framework and set twenty quality standards focussing on outcomes for service users. A recent survey carried out by the head office had very limited response from the homes in the Southampton area. The manager provided a written summary of this audit however the input from this home could not be determined and the manager was unsure if anyone had been involved. The quality report discussed the implementation of Reach 2 and My Life standards from April 2006 however there is no evidence of this taking place within the home. Regulation 26 visits take place on a monthly basis by a representative of the registered person. The manager recognised the need to develop more service user involvement in the running of the home. The manager spoke about developing meetings and service users making decisions supported through the implementation of person centred planning approaches in the home. The inspector confirmed by examining the homes servicing records that the alarm system has been serviced regularly. Weekly alarms tests are completed and fire drills are undertaken. Staff training in fire safety is up to date. The home does not have a fire risk analysis and the deputy manager was given advice on contacting the Fire Safety Officer to determine what is required in this document. 1-2 Orchard Mews DS0000059159.V319142.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 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 1 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 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.V319142.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA2 YA6 Regulation 14(1) 15 (1)(2) Requirement Service users must have a full assessment of their needs in place. Service users must have a care plan that documents their needs and the response to meeting these needs. These plans must be kept under review. Medication must not be dispensed from the receptacle it is provided in by the pharmacy to another receptacle for storage and later administration. Records must be kept of the authorisation that staff have had to carry out invasive medical procedures for individual service users. Repeated requirement timescale of 06/01/06 partly met. A log of all complaints must be kept in the home giving detail of the action taken, outcome of the complaint and the timescales. Repeated requirement timescale of 06/01/06 not 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 26 Timescale for action 07/04/07 07/04/07 3. YA20 13(2) 07/03/07 4. YA20 13(2) 07/04/07 5. YA22 22(4) 07/03/07 met. 6. YA23 20(1) The home must demonstrate how service user’s monies are being managed to include confirmation that the monies is not being held in an account used for the running of the business and that service users are receiving interest on the money they have deposited. Recruitment records must be held for all staff to include two references, proof of identity and evidence of the completion of a CRB and POVA check. Repeated requirement timescale of 14/1/05, 20/5/05 and 06/01/06 not met. 07/04/07 6. YA34 19 Schedule 2 07/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1-2 Orchard Mews DS0000059159.V319142.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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.V319142.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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