Inspection on 17/08/05 for 12 Orchard Mews

This inspection was carried out on 17th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

12 Orchard Mews 19/06/07

12 Orchard Mews 27/09/06

12 Orchard Mews 29/11/05

12 Orchard Mews 22/02/05

12 Orchard Mews 24/06/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

Stallcombe House

Stepping Stones

Cornerstones

Bethesda

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 12 Orchard Mews Gillingham Dorset SP8 4RE Lead Inspector Veronica Crowley Announced 17 August 2005 th 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 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 Stationary 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. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Orchard Mews Address Gillingham Dorset SP8 4RE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01747 826338 SCOPE Mr P Coe CRH 3 Category(ies) of PC, 3 registration, with number of places 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Orchard Mews provides the opportunity for semi-independent living to three adults who have some degree of physical disability. One or more of the service users accommodated may also have a learning disability, this is usually of a mild to moderate degree. The house is a detached property in a residential area and the service users live communally sharing all aspects of running the household. The service is operated by SCOPE, a ‘not-for-profit’ organisation providing services to people who have physical disabilities. Management and staffing of the home is undertaken from Mulberry Court, which is the administrative centre for the group of related services in Gillingham operated by SCOPE. The aims and philosophy of the service seek to promote the independence of service users by providing the degree of support necessary to achieve their chosen daily lifestyles, and also by providing opportunities for service users to develop skills that will support independence. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was arranged with the Manager and service users and took place during the day and evening of 17th August 2005. The inspector was new to the service and so it was considered beneficial for the inspection to be announced on this first occasion. An unannounced inspection had taken place on 22nd February, 2005 establishing that service users continued to enjoy a high degree of satisfaction with the support and care provided, underpinned by a strong emphasis on equality, independence and human rights. Three service users were being accommodated at the home at the time of the inspection, although the inspector was only able to speak with two as one service user was away for a few days. The two service users gave a guided tour of their home and chatted freely about their lives, their aspirations for the future and the continued support they receive from staff. The inspection involved time spent at Mulberry Court, which is the administrative and staff base for Orchard Mews, where the Manager and staff were spoken with and records and documents examined, including the two service user case files. The Commission also received comment cards back from three health professionals and three relatives. All responses received were discussed fully at the inspection and pertinent comments incorporated within the report. All nineteen key standards were assessed at this inspection. What the service does well: The service users at Orchard Mews enjoy excellent outcomes. The home has an effective and thorough assessment and care planning process which involves the service user fully. Service users’ rights are respected with service users making their own decisions and choices. Staff are proactive in ensuring that service users can be as independent as possible offering minimal support where necessary. Service users participate fully in the running of the home, including decisions about meals, housework, trips, meaningful employment and education opportunities. The home excels in ensuring good relationships inside and outside the home are maintained. They also enjoy good links with the community which supports and enhances the service users’ social and educational opportunities. Choice and variety of food is excellent with service users catering for themselves with minimal staff support. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 6 Care plans detail the assessed health needs of service users and records seen also demonstrated evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear, comprehensive arrangements in place to ensure service users’ medication needs are met. There are robust systems and policies in place in relation to complaints and for the protection of vulnerable adults. None had been reported in the last year demonstrating that the service users’ welfare is being protected and promoted. Orchard Mews offers a good standard of accommodation, which is domesticated comfortable and homely. The Manager and his staff team are competent and confident in their jobs and enjoy excellent relationships with the service users. Comments received from health professionals and service users were extremely positive. The Manager oversees and monitors the service well and is committed to training, supervision and reflective practice which ensures positive outcomes for the service users. What has improved since the last inspection? What they could do better: Policies, currently in draft, on sexuality and personal relationships should be verified and made available to staff in order for them to guide and support service users appropriately. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 7 Although SCOPE provide a comprehensive and full training programme, particularly in diversity areas, consideration should be given to race equality and anti-racism training. 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. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 No new service users had been admitted within the last year so this standard was difficult to assess, however by examining care files it was clear that full assessments had been undertaken ensuring the service could meet the identified needs of individuals. EVIDENCE: SCOPE has a comprehensive admission and placement policy, including a preadmission assessment. From records seen, the home had obtained a Care Management Assessment in addition to completing an in-house assessment prior to admission. This assessment identified the care hours needed to meet the service users’ needs. The home had also obtained information and assessments from the service users previous placement. The pre-admission assessment identified the care hours needed to the meet the service users’ needs, and detailed any known risks or restrictions needed on freedom of choice. There was evidence that the service users were involved in the assessment, they had signed the documents and the plans were written in their words. The working records also evidenced that the views of the families are taken into account, and that staff liaise with families where appropriate. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 & 9 The care plans are comprehensive, up to date and cross-reference to action plans, demonstrating that staff are conversant with the service users changing needs and personal goals and able to support them appropriately. The systems for service user consultation in this home are good with a variety of evidence that indicates that service users’ views are sought and acted upon. Since the last inspection the home has expanded upon and included more detail in individual risk assessments ensuring greater safety for service users. EVIDENCE: Two care files were examined in detail. Care files included an up to date Care Plan and Assessment. Through discussions with service users and staff it was clear that care plans are updated every six months with full participation of service users. The care plans seen were accurate, thorough and covered all areas of personal and social support, associated health needs and a ‘working’ Action Plan. The care plans also include where specialist input is needed and how staff support service users in accessing these services. Care plans are written in the first person and set out both short term and long term goals based on the wishes and aspirations of the service users. Evidence was seen 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 11 where staff have supported and are continuing to proactively support service users to reach their goals. Following discussions with service users they confirmed that there were no restrictions of choice or freedom in place. Where extra supervision by staff is needed for a particular activity (i.e. using public transport, cooking) this followed a risk assessment, and was recorded in the service users care plan. The Manager and staff are proactive in promoting the rights of service users to make decisions and control their lives. This was evidenced by talking with the service users, staff and by examining the daily records. Staff provide service users with information and assistance in order to support the service users making their own decisions and choices. Examples include providing information on day opportunities, holidays, clubs, advocacy, health services and personal relationship guidance. Service users have been supported to manage their own finances, go shopping independently and in deciding the level of support they need. There were no significant limitations placed on service users in relation to their choices or human rights. All three service users manage their own finances. There are monthly service user house meetings, joint with the other SCOPE homes in Gillingham, where service users are able to discuss the running of the home and issues they may have with the organisation. Both service users reported that they were happy with the level of independence and decision making they have within the home. A comprehensive, user-focussed risk assessment policy and procedure is in place. Risks are well documented and focus on enabling service users to continue to take responsible risks and maximise independence. Where, from the case files examined, risks had been identified following a needs assessment these had been duly recorded. Examples of these included using the kitchen, managing own finances and specific health problems. As with care plans, risk assessments are updated every six months. Service users also receive support and training where necessary – such as Health and Safety training, road safety and personal safety when out and about in the local and wider community. Following a recommendation at the last annual inspection the home had since improved an individual risk assessment by expanding the recorded detail (i.e. stating the specifics of the support required). 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users are well supported to take part in meaningful, appropriate jobs and education or training opportunities in order to achieve their full potential. Links with the community are excellent which support and enhance service users’ social and educational opportunities. The service users enjoy excellent relationships inside and outside the home and maintain good family links, which enrich their lives. The daily routines promote independence and individual choice facilitating and supporting service users to achieve their individual goals. The meals in the home are good offering both choice and variety and cater for special dietary needs. EVIDENCE: 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 13 All of the service users living at Orchard Mews work at the nearby Thorngrove Garden Centre. The Garden Centre is an established local business and provides a real working environment as well as the opportunity to gain a range of social and work related skills. Service users can choose how many days they work in the Garden Centre. One service user was also working at another Garden Centre and in a local pet shop. Another service user attends a local college undertaking a computer course. The service users spoken with were fully aware of the local activities and support offered by specialist organisations and confirmed that staff assist them with gaining this information (for example PHAB club, DAB club, Riding for the Disabled, Local Disability Action Group, NorDis, Lifestyles and Stepping Stones). The care plans examined demonstrated that service users participate fully in the community, that they regularly go shopping, out for day trips, to the cinema, pub, skittles and swimming. The service users can join in the planned activities arranged by Mulberry Court (a larger SCOPE home near by) should they so wish. Staff provide support in the home during the approximate hours of 4:30pm to 8:30pm each day. If a specific request is made for staff support at any other time the manager confirmed that this can be provided. It is a recognised part of staff duties to provide support out of the home including evenings and weekends. The home has the use of a car and a minibus to support service users in accessing community activities if needed. The service users stated that they generally enjoy good relationships with their neighbours and local shop keepers. This standard is exceeded. The needs of the service users in relation to social and well-being are very well documented. Staff remain committed to supporting family links and friendships, but are also careful to ensure that service users determine who they see and when. All three service users have contact and friendships with disabled and non-disabled people. Support plans detail information about social contacts and significant people in the lives of the service user, and daily care records include entries relating to contact with families, friends and acquaintances. They are also encouraged to have friends and family to visit including for dinner and/or parties/celebrations. This standard is exceeded. Service users are free to develop and maintain intimate personal relationships, and staff support the privacy of this while offering support and guidance where necessary. The Manager reported that he had been involved in a working group to develop appropriate policies on sexuality and personal relationships. To date these policies have not been ratified and a recommendation is made for this to be addressed, in order for staff to guide and support service users appropriately. Orchard Mews is set up as the private home for three service users. They are very much autonomous, free to make their own decisions with minimal support and guidance from staff. Staff enter the home with permission only, and it is 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 14 only the service users who have a key to the home. The service users have personalised the whole home to their taste and are responsible for the security of the premises. The service is flexibly delivered and shaped by the service users needs and wishes, who do their own shopping, cleaning and the majority of the cooking. The service users are semi independent with their cooking. They draw up a menu each week for their evening meals and one service user goes shopping for the food each week with support from staff. Service users go shopping independently for their lunch and breakfast food. The service users decided themselves that they would eat altogether in the evenings with one person cooking the meal for all of them, but that they would buy their own food for lunches and breakfasts. They put an agreed amount in a kitty each week for the food for the evening meal. Only the three service users have access to this kitty. A staff member supports the service users in cooking the evening meal and guiding them into eating nutritious and healthy food. This support is flexible depending on the level of need of the service user. The menus seen evidenced that the service users eat a varied and balanced diet. The home has provided service users with suitable equipment in the kitchen, and aids that enable them to be more independent. There are ample plates, cutlery, glasses, saucepans etc. This standard is exceeded. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Although service users require minimal personal support staff ensure consistency and continuity of support for them through the allocation of designated key-workers, concise individual working records and partnerships with advocates, family, friends and relevant professionals. The health needs of the service users are assessed and well met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear, comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: The service users living at Orchard Mews require minimal staff support with personal care. They have detailed care plans and assessments which outline the exact support they require and prefer. If they do require some support this is in agreement with the service user and any other professionals / family where appropriate. The service users each have independent routines and can get up and go to bed when they choose. Through discussions with the service users and by examining their care plans it was evidenced that service users receive additional specialist support as needed, e.g. from physiotherapists. Each service user has an independent key-worker and they commented that 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 16 this relationship is useful and beneficial. SCOPE have been endeavouring to positively recruit male workers as the three service users at Orchard Mews had commented that they would prefer this. Despite great efforts the recruitment campaigns have not been successful in recruiting male workers but have report successfully having managed to recruit workers with a disability. The care files and daily records evidenced that the healthcare needs of service users are assessed and met within the home. The care plans set out the support needed to meet their needs. The service users are semi-independent in accessing the doctor/dentist/opticians. Staff support is arranged with the focus of enabling the service user to be as independent as possible, therefore ranges from prompting service users to attend appointments to supervising the service user with attending and sitting in on appointments. Service users have a choice of GP, although they all attend the local village surgery. Staff have received training in managing specific needs such as epilepsy. The home has a robust medication policy. All staff complete an induction in administering medication. This is an informal training session as part of SCOPE’s induction for new workers. A number of staff had completed a ‘Safe Handling in Medicines’ course and in addition the local Pharmacist provides specific training on medicines used in the home. At present staff do not support any of the service users with medication. The one service user who takes medication is completely independent with this as he orders and administers his own. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Robust systems and effective adult protection training ensures that service users are protected from abuse and that their welfare is being promoted. EVIDENCE: The service users spoken with knew who they could complain to, and stated that they were confident any complaints would be addressed fairly. Further evidence of this was found in the minutes of house meetings and in the Individual Working Records, where it was noted that staff give service users the opportunity to complain or raise concerns, and listen to any worries the service users may have. Information on how to complain is detailed in the home’s Statement of Purpose, in the Service User Guide and in a leaflet given to service users titled ‘Complaining isn’t wrong – it’s a Right’. SCOPE have a designated complaints officer to deal with service users formal complaints. The Manager reported and the comment cards received from relatives and health professionals confirmed that no complaints had been made against the home since the last inspection and that refresher training on ‘dealing with complaints’ was scheduled for September 2005. SCOPE has robust policies and procedures in place and staff undertake regular training in relation to the protection of vulnerable adults. There is an identified adult protection officer for Orchard Mews (the Deputy Manager based at Mulberry Court) and an Adult Protection Team based at SCOPE’s Head 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 18 Quarters. The Adult Protection Officer attends regional conferences on best practice and key issues relating to Adult Protection. A copy of the Local Interagency ‘No Secrets’ guidance was seen at Mulberry Court. The Manager reported that there had been no Adult Protection referrals since the last inspection. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The standard of the environment within this home is good providing service users with a clean, bright and homely place to live. EVIDENCE: Orchard Mews is a detached modern house on the outskirts of Gillingham. There is level access to the front and ground floor of the house, however, it would not be suitable for accommodating people who use wheelchairs as all three bedrooms are on the 1st floor. The home adequately meets the needs of the current service users in a homely and comfortable way. Each service user has a single bedroom; a fourth bedroom is used as an emergency staff sleep-in room or a visitors/guest room. There is a bathroom and separate shower room on the 1st floor and a WC on the ground floor; all of these facilities are of a good size. On the ground floor there is a lounge with patio door to a well stocked garden, and a kitchen. The kitchen accommodates a small table and 3 chairs for a dining area. Furnishings and decoration are domestic in style. The standard of decoration was good throughout and again reflects the tastes of the service users. A large garage provides storage for Bartcars, bicycles and a second freezer. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 20 The house is owned and maintained by a local housing association, which undertakes all maintenance of the property. There are records kept of repairs or renews needed and these records indicate the repairs are undertaken in good time. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The staff fulfil the aims of the home and meet the changing needs of the service users through good programmes of training and development further supported by regular supervision. EVIDENCE: SCOPE has developed an Induction and Foundation training pack for all new staff, which meet the ‘Skills for Care’ standards (previously TOPSS). The staff team not only work at Mulberry Court but also at three other community homes run by the organisation in Gillingham. SCOPE provide regular training for staff in all key areas (for example first aid, manual handling, food hygiene, adult protection, risk assessments). A training events calendar is produced annually and staff are also encouraged to undertake training courses external to this. The Manager confirmed that staff are all up to date with mandatory training and random checks on the records of four members of staff further evidenced this. The training is linked to the home’s service aims and to service users needs. For instance staff have received training in epilepsy, diabetes, disability equality and autism. In addition over 50 of the staff team hold their NVQ Level 2 award. The organisation is also funding a number of staff to undertake the NVQ level 3 award. Staffing for Orchard Mews is provided from Mulberry Court. Currently 25 of staff at Mulberry Court have a disability clearly demonstrating SCOPE’s 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 22 commitment both to issues of equality and to reinforcing positive role modelling for the service users. Each member of staff has a training needs assessment completed annually. Staff also confirmed and records seen further evidenced that staff receive regular supervision in order to enhance their skills and receive support and professional guidance. Whilst speaking with staff it came to light that although SCOPE provides excellent disability equality training there has been no race equality or antiracism training and a recommendation is made for this to be considered. Both service users spoken with confirmed they were happy with the support offered by staff and enjoyed good relationships with them. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 There are robust systems in place for monitoring the performance of the home against its’ Statement of Purpose and The Care Homes Regulations to ensure service users achieve good outcomes. The health, safety and welfare of the service users is promoted and protected by a huge variety of excellent risk assessments, good monitoring and recording systems and a trained staff team. EVIDENCE: There was evidence of continuous self monitoring, involving service users. Yearly reviews are carried out with the service users and their family/ representatives / friends. This review monitors how the service users’ goals and care plans have been achieved. In addition service users are formally asked their views about the service provided to them. The results from this years’ survey demonstrated that the service was performing at 3.4 3 equalling good and 4 equalling excellent. This was slightly lower than last year and plans are to be formulated in order to address issues brought up for 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 24 improvement. A staff satisfaction survey had also been undertaken, but analysis of the findings was yet to be finalised. Regulation 26 visits are carried out monthly and copies of reports sent both to the home and to the Commission. A copy of the Annual Development Plan was also seen on the service users notice board at Mulberry Court. The service users confirmed that they are informed of any announced inspections and are encouraged to talk with inspectors. SCOPE are proactive in keeping up with all relevant guidance and legislation and any requirements or recommendations that have been made in the past have all been addressed within the agreed timescales. Examination of maintenance and safety records indicated that all checks, testing and servicing of equipment and systems were being undertaken at the recommended intervals. There is a designated staff member responsible for health and safety, fire precautions and first aid. Service users have also had training in personal safety, manual handling and food hygiene. Appropriate policies and staff guidance were in place and all staff receive training in first aid, manual handling, health and safety (including COSHH and Infection Control) and food hygiene. Risk assessments examined were being used to support safe working practices. Accidents and Incidents had been recorded accurately and appropriately and where necessary notified to the relevant agencies. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 4 x 4 3 4 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Orchard Mews Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 26 NO 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 15.5 35.4 Good Practice Recommendations The draft policy on sexuality and personal relationships should be formailsed. Consideration should be given to providing race equality and anti-racism training. 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road, Poole Dorset BH17 0NF National Enquiry Line: 0845 015 0120 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 12 Orchard Mews D55 S26740 ORCHARD MEWS V238007 170805 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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