Inspection on 23/01/06 for Brandley Ltd. (Orchid House)

This inspection was carried out on 23rd January 2006.

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 no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brandley Ltd. (Orchid House) 16/06/06

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Brandley Ltd. (Orchid House) Orchid House 49 Elsenham Road Manor Park London E12 6JZ Lead Inspector Anne Chamberlain Unannounced Inspection 23rd January 2006 10:10 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brandley Ltd. (Orchid House) Address Orchid House 49 Elsenham Road Manor Park London E12 6JZ 0208 478 1517 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) Brandley Ltd. Ms Beverley Beaupierre Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow the home to provide continuous care for a named service user, who is now over the age of 65 years. N/A Date of last inspection Brief Description of the Service: Orchid house is run by Brandley Residential Homes. The home is a three bedroomed property in a residential road in the borough of Newham. The home is registered for three adults between the ages of 18 and 65. However a variation has been obtained for a service user who is now over 65 years of age. The service users all have a learning disability. The home offers care and support in a homely environment. There are pleasant shared spaces including a family kitchen and a nice little garden. Showering, bathing and toilet facilities are good. The office/sleep in room is located upstairs with an en-suite shower room. There are currently three service uers living at Orchid house and they are supported by a one staff on every shift, including sleep in night staff. Service users have access to day services and they are enabled to participate in community leisure activities. Service users are supported and encouraged to be as independent as possible. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the service which opened in April 2005. The inspection was unannounced and the aim was to ascertain how well the service users are settling into the home and how the service is meeting the key standards of regulation. The inspection took place over one short day. The inspector spoke with two service users and interviewed the manager. She looked around the home and viewed key documentation as well as three service user files and three staff files. The inspector would like to take this opportunity to thank the service users, staff and manager at Orchid House for their co-operation and assistance with the inspection. What the service does well: The service provides a homely but structured environment for service users. From this secure base they are supported to access the community safely. The ethos of the home is to empower independence and choice and staff integrate these values into their work with service users. The service has weaned a service user off of two medications) which she did not really need (and which have unpleasant side effects). Another service user has improved his diet and no longer needs a supplement. One service user with whom the inspector spoke was rather reserved but did indicate that he is comfortable, likes his room and also likes the food. Another second service user said that Orchid House was a better place. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. The home would carefully consider referral information before offering a placement to an individual. EVIDENCE: The home opened less than a year ago with the three service users who are currently in placement there. There have been no new admissions. The inspector viewed the assessment information on the three service user files. All three service users had referral information from Newham including assessment of activities of daily living. There were other items of information for example a set of behaviour guidelines for an individual, in addition. The inspector understands from the manager that the transition arrangements were good and the service users have settled very well. The inspector was unable to locate on service users files, contracts with terms and conditions. The manager was able to run off a copy of the contract for one service user but it was not signed or dated. The manager stated that originals of the contracts were signed and dated but was not able to locate them. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 9 The manager must ensure that service users have contracts with terms and conditions, signed by both parties, and a copy is kept in the service user file. This is a requirement. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 the following standard(s): 6,7 and 9. The home has collected a great deal of assessment information but needs to record this accessibly. Service users are assisted to make decisions about their lives. They are supported to take some risks as part of a more independent lifestyle, but there is a lack of risk assessment evidence. EVIDENCE: Two service users had proposed care plans from Newham, but there was no recording on file of Orchid House undertaking assessment of the service users following their admission to the home. The manager was able to show the inspector a multi-media presentation (on a lap top) for one service user, entitled Life Story. She advised that the service user had fully contributed to the making of this programme, including discussing goals and choosing the background music. The life story should feed into a person centred plan (the equivalent of a service user plan) which can then be updated. The manager stated that the presentation will be burnt onto a CD and laminated sheets will be made which can then be filed as hard copies on the service user file. The Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 11 manager showed the inspector the files set up for all three service users, ready to receive these laminated sheets. The inspector felt that the person centred plans would be authentic meaningful documents which service users would fully participate in. The manager did agree that creating these plans can take months as service users make their contributions when they feel inclined to participate. The inspector was concerned that in the meantime there were no service user plans recorded on file. The inspector understands that in this small home information is shared verbally, but would point out that Regulation 15 quite clearly requires the registered person to prepare a written service user plan as to how the service users needs in respect of his health and welfare are to be met. The manager must ensure that there is a service user plan for each service user. This is a requirement. The manager advised that one service user had had a case meeting and an action came out of this to improve links with his brother. This was supported and the service user saw his brother on boxing day. However there was no record on file of the action or the meeting of it. The manager must ensure that service user plans are reviewed and updated regularly. This is a requirement. The manager explained that the service users have different abilities for making choices, linked to their communication needs. Service users choose their clothes, when they want to go to bed, what they would like to eat and with whom they want to dine. Unfortunately there was no documentary evidence on file to support this information. The inspector did see a laminated sheet which referred to bed changing days and demonstrated that service users had chosen different days on which they wanted to change their bed linen. The inspector stated that risk assessment meetings have been planned with care managers but have been rescheduled and cancelled. The inspector found no risk assessments on two of the three service user files. The third file contained a general risk assessment which highlighted several areas in need of assessment. The inspector advised the manager that risk assessments need to be developed showing how specific risks are to be managed and reduced. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 12 The manager must develop and record comprehensive risk assessments for all three service users. This is a requirement. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Service users take part in appropriate activities and are becoming part of the local community. Relationships with family and friends are supported and service users are respected with their rights and responsibilities recognized. Healthy eating is encouraged and mealtimes are enjoyable. EVIDENCE: Two service users attend day centres, another has retired from day services and has an individualised programme. Service users also socialise with service users from the other Brandley home, two of whom are old friends. Service users all decided they did not want to go to a pantomime this year. However they had all been out the day before the inspection, to a London attraction. The manager advised that one service user likes walking, all the service users like to go to pubs for meals and there will shortly be the opportunity to go to a local church as a group. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 14 The home encourages and supports contact with families and friends. One service user has a brother with whom he has contact, another has two sisters whom she sees. The home has made attempts (unsuccessful so far) to trace the father of one service user. They are using the services of an agency called Trackers International. Service users bedrooms can be locked from the inside. The manager stated that the three service users have been offered keys to the front door, although they have all declined. The manager stated that service users are encouraged to take responsibilities for example for domestic tasks like helping change their beds. The manager stated that some of the service users had come to the home with rather limited tastes in food, preferring a quite restricted diet. The home has encouraged them to broaden their dietary horizons and health benefits from this have been noted. The home does not have menus as such. The manger explained that a number of basic foods are stocked and service users are encouraged to go shopping with staff to choose foodstuffs. Service users are offered choices and there is discussion about food and what people would like to eat. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 the following standard(s): 18,19 and 20. Service users receive personal support but it was difficult to evidence how this was provided in the way they prefer. Physical, emotional and health needs are met, but practice is not supported with recording. The arrangements for the administration of medication are sound, but some improvements are required. EVIDENCE: None of the service users has a physical disability and all have a level of independence in personal care. However the inspector was not able to locate on service user files any current information as to how they prefer to have personal support. As previously stated there is a need for individual service user plans which would incorporate this information. The manager advised that one service user has been able to come off two medications which she has been taking for years. Documentary evidence to support this was seen on her file. She also advised that another service user has been able to stop taking a preparation because his improved diet contains more fibre. One service user had been advised by his general practitioner to reduce his intake of sugar and this had been recorded in his log book. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 16 Service user folders had a section entitled information about my health. One file contained the information mentioned above regarding coming off medication, but in two cases the sections were empty. The inspector understands that the individual log books for service users would probably contain entries about visits to health professionals, but it would been necessary to know the approximate date of the visit to find the recording. The manager stated that she is satisfied that staff read the log books when they come on duty, and information is handed over. The inspector believes, based on the caring ethos of the home, that the physical, emotional and health needs of service users are met but evidence of this needs to be properly recorded. The manager must ensure that proper recording of the meeting of emotional, physical and health needs is made available for inspection. This is a requirement. The inspector viewed the medication policy. It is titled medication policy summary. Since it is the only policy on medication the word summary is confusing and should be deleted. The manager advised that the policy links to other policies and if so this should be stated in the policy. The inspector viewed the arrangements for the administration of medication. All service users have lockable medication cabinets in their flats. The keys are carried by the staff on duty. Only one service user takes medication. The inspector viewed the medication administration chart and checked tablets remaining for two drugs. There was no discrepancy. The system for recording medication into the home was seen and was satisfactory. The manager advised that if they needed to return unused medication they would take the blister pack to the pharmacist who would give them a slip. This has never happened so it was not possible to evidence. The inspector advised the manager to ensure that she gets a signature from the pharmacist for returned medications. The manager must ensure the following with regard to the administration of medication. The word summary is deleted from the medication policy title. The policy makes appropriate reference to other policies to which it is linked. This is a requirement. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23. Service users are encouraged to express their views which will be listened to and acted upon. They are protected from abuse, neglect and self-harm. EVIDENCE: The inspector viewed the complaints policy. It needs to be amended to state that service users can contact the Commission for Social Care Inspection (CSCI) direct at any time. The manager must amend the complaints policy to state that service users can contact CSCI direct at any time. This is a requirement. The inspector viewed the complaints sheets which would be used for recording complaints and tracking the progress of their resolution. She was a little concerned that no complaints at all have been received since the service started up. The manager explained that the service users have come as a group from a setting which was rather institutionalised. They are being encouraged to make choices and to express their views. Monthly house meetings are held and these provide a forum for discussion of issues. The manager stated that a house meeting took place the day before. Unfortunately there were no minutes available for inspection but the inspector did see the event diaried in the house diary. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 18 The inspector viewed the adult protection procedural guidelines and also saw a flowchart provided for guidance. Both were satisfactory. The manager stated that all service users need support with managing money and CRAG is appointee for all three. The manager understands that the practice was for benefits to be paid directly in Nationwide accounts. However no benefits have been paid in since the service users arrived at the home. All the service users have been referred to Citizens Advice Bureau (CAB) for support to sort this problem out. In the meantime Brandley provide the service users with the personal allowances they would normally receive and this is incorporated into their fees. The inspector viewed the accounting for the personal allowances, which the service users spend in cash. One account did not balance and the manager stated that it was not fully up to date and that the monies are not balanced at every handover. The inspector recommends that the service users monies and accounts are balanced at every handover to eliminate errors. This is a recommendation. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30. The home is clean and hygienic, safe and comfortable. It offers a homely environment to service users. Some new furniture is needed in the lounge to ensure the comfort of service users. EVIDENCE: The environment at Orchid house is homely and comfortable. The kitchen is particularly welcoming with space for everyone to sit and eat together. The inspector noted and the manager agreed, that the two sofa’s in the sitting room are beyond their useful life and need urgent replacement. The manager must replace the two sofa’s in the sitting room. This is a requirement. The home was clean, hygienic and free from any offensive odours. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 20 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. The home employs staff who are competent and qualified. Recruitment practice in not adequately robust and staff training levels could be improved. Formal supervision of staff is inadequate. EVIDENCE: The home’s statement of purpose states that all care staff are “selected for their qualities of reliability integrity skill, friendliness and professionalism”. It further states that “all care staff will work towards a minimum qualification of NVQ level 2”. The inspector noted that the usual staffing arrangement is for one member of staff to be in sole charge at Orchid House. She would stress the importance of the above and the desirability of staff achieving the higher levels of NVQ. The inspector viewed the staff recruitment policy. The sentence ‘In exceptional cases verbal references may be sought and accepted’, must be deleted as neither the inspector or the manager could think of any circumstances in which this could apply. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 22 The manager must ensure that the sentence ‘In exceptional cases verbal references may be sought and accepted.’ is deleted from the staff recruitment policy. This is a requirement. The inspector viewed three staff files. She noted that there were no references on file for a staff member who started at the home mid 2005. The manager stated that the references had been received and subsequently lost. The manager must ensure that all staff have two written references and that these are available on file for inspection. This is a requirement. One staff file had a service contract but it was not signed or dated. A second staff file had no contract on file. A third staff file had a contract which was signed by both parties and dated. The manager must ensure that all staff have service contracts on file which are signed by both parties and dated. This is a requirement. Staff files contained a section for training records. In two of the three files viewed this section was empty. One file contained evidence of health and safety induction training. One file contained training certificates but the worker had done only one day of training in 2005 which was for multimedia advocacy. The manager stated that this worker had renewed training in 2004 and had during 2005 been concerned with achieving NVQ 2 which she said has some overlap with core training. The manager must ensure that:Staff receive induction and basic training, and that core elements of training are renewed regularly. The above is evidenced in individual staff training profiles which are up to date and are available for inspection in staff files. This is a requirement. The inspector viewed the records of supervision for the year 2005 in three staff files. One worker had had supervision in April, August and November one in November only, and one in December and May. The expectation is for staff to Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 23 have supervision meetings six times a year. The level of supervision in the home falls far short of this. The manager must ensure that staff receive supervision six times a year. This is a requirement. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Service users benefit from a competently run home. Their views underpin the development of the home. Health and safety is promoted but two requirements have been made to improve practice in this area. EVIDENCE: The registered manager has relevant qualifications and experience to run the home. She has just completed the registered manager’s course. The manager explained that the three service users all tend to be rather passive and need encouragement to express their thoughts. The home are working to empower choice. The manager has also developed but not used yet, quality assurance forms for visitors, a quality assurance audit form, and client survey sheet. The inspector looks forward to her next inspection when more tangible evidence of quality assurance work should be available. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 25 The inspector viewed the Control of Substances Hazardous to Health (COSHH) register with risk assessment forms. Four items were listed but only one form had been completed, in respect of bleach. The manager stated that she has difficulty in obtaining product information but that the home is working with a company called MJL who might supply product information. The manager must ensure that all substances used in the home have a recorded risk assessed. This is a requirement. The inspector asked to view the incident and accident books. No incident book exists but there are incident sheets, however none had been completed. The inspector is aware that a service user went missing from his day service and a regulation 37 notification was sent to the Commission for Social Care Inspection (CSCI). No incident sheet had been completed for this. The manager must ensure that incident sheets are completed appropriately and retained as a record. This is a requirement. The manager stated that there is an accident book but she could not find it. She stated that the book has two copies of each recording. One stays in the book and one goes to the health and safety person who is herself. She said that there had been no accidents since the home opened. The inspector viewed the fire risk assessment for Orchid House. The manager stated that the fire alarms are tested every Monday and that the home has three fire drills per year. The emergency lighting comes on when the fire alarm is tested. The inspector advised the manager to conduct a fire drill at night. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 26 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 2 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 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 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 2 2 x 2 x 3 x x 2 x Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 27 N/A 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 5 Regulation YA5 Requirement The manager must ensure that service users have contracts with terms and conditions, signed by both parties, and a copy is kept in the service user file. Timescale for action 01/03/06 2 6 YA15 The manager must ensure that there is a service user plan for each service user. 01/03/06 3 6 YA15 The manager must ensure that service user plans are reviewed and updated regularly. 01/03/06 4 9 YA14 The manager must develop and record comprehensive risk assessments for all three service users. 01/03/06 5 19 YA12 The manager must ensure that proper recording of the meeting of emotional, physical and health needs is made available for inspection. 01/04/06 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 28 6 20 YA13 The manager must ensure the following with regard to the administration of medication. The word summary is deleted from the medication policy title. The policy makes appropriate reference to other policies to which it is linked. 01/04/06 7 22 YA22 The manager must amend the complaints policy to state that service users can contact CSCI direct at any time. 01/04/06 8 24 YA23 The manager must replace the two sofa’s in the sitting room. 01/04/06 9 34 YA19 The manager must ensure that the sentence ‘In exceptional cases verbal references may be sought and accepted.’ is deleted from the staff recruitment policy. 01/04/06 10 34 YA19 The manager must ensure that all staff have two written references and that these are available on file for inspection. The manager must ensure that all staff have service contracts on file which are signed by both parties and dated. 01/03/06 11 34 YA19 01/04/06 12 35 YA18 The manager must ensure that:Staff receive induction and basic training, and that core elements of training are renewed regularly. 01/04/06 Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 29 The above is evidenced in individual staff training profiles which are up to date and are available for inspection in staff files. 13 36 YA18 The manager must ensure that staff receive supervision six times a year. 01/03/06 14 37 YA17 The manager must ensure that 01/04/06 service users have contracts with terms and conditions, signed by both parties, and a copy is kept in the service user file. The manager must ensure that incident sheets are completed appropriately and retained as a record. 01/04/06 15 42 YA17 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 23 Good Practice Recommendations The inspector recommends that the service users monies and accounts are balanced at every handover to eliminate errors. Brandley Ltd. (Orchid House) DS0000062815.V279697.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Brandley Ltd. 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