Inspection on 18/01/06 for Cherry Orchards Camphill Community Ltd

This inspection was carried out on 18th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherry Orchards Camphill... 24/09/07

Cherry Orchards Camphill... 01/11/06

Cherry Orchards Camphill... 08/09/05

Cherry Orchards Camphill... 08/12/04

Cherry Orchards Camphill... 26/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

Clouds House

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Cherry Orchards Camphill Community Ltd Canford Lane Westbury On Trym Bristol BS9 3PF Lead Inspector Nicky Grayburn Unannounced Inspection 18th January 2006 09:30 Cherry Orchards Camphill Community Ltd DS0000026530.V276583.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 Cherry Orchards Camphill Community Ltd DS0000026530.V276583.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. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cherry Orchards Camphill Community Ltd Address Canford Lane Westbury On Trym Bristol BS9 3PF 0117 9503183 NONE 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) Cherry Orchards Community Limited Mrs Hilda Karin Van Rooy Care Home 21 Category(ies) of Past or present alcohol dependence (21), Past or registration, with number present drug dependence (21), Learning of places disability (21), Mental disorder, excluding learning disability or dementia (21) Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 21 persons aged 18 - 64 years of age Date of last inspection 8th September 2005 Brief Description of the Service: Cherry Orchards is a therapeutic community, set on 18 acres of land, yet it is within reach of local shops and amenities. It is registered to provide accommodation and personal care for people with mental health needs. The community is based upon the philosophy of Rudolf Steiner. The number of registered places include all rooms inclusive of the co-worker’s rooms. The community feels that it works best with 12 residents. Voluntary co-workers live on site in the two main buildings with the residents, providing 24-hour support. Bedrooms are large with very pleasant views over the land. A large emphasis of the day-to-day living is based upon tending the land and the animals. There is a large landscaped garden with numerous areas to sit and relax. There are also two gardening employees and a therapist. The service is not suited for people who have difficulties with mobility. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. The inspector spent a day at the community and gathered evidence through talking with the two managers, coworkers and residents; having lunch at one of the homes, and being present during the morning ‘Gathering’ when everybody meets to discuss the forthcoming day. The inspector also examined various key documents kept at the home. For the purpose of this report, unless specified, the two managers and volunteer co-workers will be referred to as staff due to the involvement of all within the community. What the service does well: What has improved since the last inspection? The garden area is becoming established and it was observed how it is a frequent place of meeting and usage by residents. Kitchen space has been freed up as the preservation and storage of fresh produce has been relocated. All staff now undergo Protection of Vulnerable Adults training that helps to protect the residents within the community. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 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. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.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 Cherry Orchards Camphill Community Ltd DS0000026530.V276583.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, 4, 5 Residents can be assured that their needs will be assessed prior to moving into the community. Information is provided to the residents and trial periods are obligatory. EVIDENCE: Due to the nature of the community, there is much work carried out prior to residents moving in to ensure that both parties are content that the style of Cherry Orchards will meet the potential’s residents’ needs. Standard 1 was not fully inspected, however; a summarised guide was read and information about the organisation ‘Camphill’ can be found on the Internet and is a worldrenowned community based service. There has been one recent admission who is presently in the ‘finding out time’ (trial period) and said to the inspector that it was a lovely place to be. Residents can become involved in all aspects of the home and then the staff team and resident draw up a programme for areas which the resident would like to focus on. Within care folders, the inspector viewed pre-assessments; care plans; risk screens, and noted telephone conversations between the home and the external professionals involved. The manager confirmed that they insist on this information prior to a resident moving in. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 9 From the four care files looked at, contracts were present and were signed by the resident. These documents include what each party can expect from each other and how to resolve issues of concern (complaints). It must be noted, that a co-worker couple, who have worked at Cherry Orchards for over a year, have a newborn baby. The residents and staff are excited about having a baby in the community. Although this can be positive, potential residents, and their professionals must be aware of this to ensure correct placements are made. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.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, 8, 9, 10 Residents are supported to make decisions about their lives. A more robust system of risk assessing would further support the residents. EVIDENCE: Whilst talking to a resident, it was pleasurable to hear about the massive improvements within their lives since living at Cherry Orchards. The resident gave examples of all the changes and achievements they have experienced, thus evidently improving their self-esteem. The resident gave examples of how staff have encouraged them to undertake certain tasks. Key Worker reports further evidenced this. The key worker sessions occur on a weekly basis and address areas of changes/developments which have become visible, developments which still need to be fostered, how to achieve them, and by whom. The reports are used as the residents’ individual care plans. Each resident also has an individual programme to follow throughout the week. These were not present in the files, but staff told the inspector that the 6-8 week programme was being currently changed according to the seasonal change. It is recommended that past and present programmes are kept in the files for staff and resident’s access. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 11 The inspector joined the daily ‘gathering’ meeting, which allows staff and residents to announce any daily appointments or to raise any concerns or matters. From the files, looked at residents have one particular risk assessment which they themselves mainly complete regarding their mental health. Some residents have additional assessments, specific to individual potentially high risks. Through discussions with the managers, co-workers and a resident, and documents in the care folders, it was evident that risk assessments are carried out in an automatic, natural manner. However, it is important that risk assessments are recorded and this was discussed with the managers. These must be documented in a format that is accessible to all to ensure that residents are fully aware of how to minimise their risks as independently as possible. The assessments must be monitored and reviewed to ensure that risk is being minimised. For example, this is especially important for residents who access the local community and have had previously distressing incidents within that environment. Due to the close proximity of all in the community, confidentiality is especially important. There are weekly ‘care circles’ where key members of staff join to discuss residents’ progresses. These meetings discuss selected residents on a rotational basis in-depth. Records are kept in the locked office. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 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 the following standard(s): 11, 12, 13, 14, 15, 16, 17 Residents are given opportunities for personal development and appropriate activities. Relationships with friends and families are supported by staff. Meals and mealtimes are extremely nutritious and are a focal point of the day. EVIDENCE: The lifestyle offered at Cherry Orchards is of a therapeutic and calm nature. It must be noted that it may not suit everybody’s needs or preferences. Residents learn and are expected to become an integral part of the community and develop their life skills. Staff encourage residents to be as independent as possible. If residents wish to access the local community, they can walk to the area. To aid selfsufficiency and growth of independence, the mini bus is not used frequently for the residents. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 13 There are various leisure activities which residents can become involved in. Residents are free to go out in the evenings if they wish, and there are frequent in-house activities provided, such as clay modelling; table tennis; relaxation; or group meetings. Due to the therapeutic environment there is no television or Internet access for the residents or staff. There are fortnightly bible sessions. A co-worker confirmed that even though Cherry Orchards is based on a Christian faith, residents do not have to participate in the sessions. The community follows the Christian calendar of celebrations and a co-worker said that everybody gets involved in the preparations. It was observed that residents have keys to their individual bedrooms; are responsible for household chores; and have unlimited access to the land and the shared spaces within the homes. Rules on smoking (unless in designated outside areas), alcohol and drugs are clearly stated as prohibited due to the promotion of health and rehabilitation. Family and friends relationships are respected. Residents confirmed that visitors are allowed to the home and are welcomed. The amount of contact varies for each resident. Staff encourage residents to think about the consequences when interacting with others and support those who are dealing with issues concerning this area. Due to the family-type community atmosphere of the service, prior to leaving the home, staff encourage and support the resident in how to manage living away from the home. This is especially important as residents can reside within the community for up to two years and strong attachments can be made. An outstanding quality of the community is the value that is placed on diet and meal times. The entity of ‘food’ is a high priority. The residents and staff are heavily involved with the horticulture of the land. There are organic vegetable and fruit yards that are then used within the home. The diet is excellent. All spoken to commented extremely positively regarding their diet and the tastiness of it. Menus were looked at and present a very balanced diet. A coworker explained how it is discussed weekly during a meeting. Within a lounge area there are lists of the seasonally available fruit and vegetables to base the menus upon. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Physical and emotional needs of residents are met and are continuously reviewed. Residents are safeguarded by a robust medication system; however, those who self medicate need to be sure the involved risks are minimised. EVIDENCE: Once the resident is settled, an individual programme is devised over a 6-8 week period. Therapy sessions are offered including autobiography work; art; movement; drama; and one-to-one sessions. Current residents do not require any personal care. Evidence was seen and a manager confirmed that Cherry Orchards expects residents to manage their own doctor, dentist and optician’s registration and appointments. It does not provide a service to those who are not independent to do so. However, a manager further confirmed, and exemplified, that those with specific secondary needs, such as diabetics, would be highly supported to manage their needs, but as independently as possible. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 15 Again, Cherry Orchards encourage residents to self medicate as independently as possible. There are only three medication administrators. The pharmacy provides the medicines monthly. The homes use their own Medication Administration Records which have been approved by the CSCI’s pharmacist and the pharmacy are content with their recordings. Risk assessments need to be carried out for those who do self medicate to ensure that any risk is minimised. One self-medicating resident told the inspector of the process and is confident of the care taken by the staff. Within the medication information folder and policy pack given to staff, policies and procedures are detailed. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are protected from abuse. Staff actively listen to the residents on a very regular basis. EVIDENCE: The previous requirement regarding residents being able to contact the Commission has been met and the contact details are on display in the main lounge and in the leaflet, which is sent out for information prior to admission. All staff undergo ‘Adult Abuse’ training. This took place in May 2005 and the newer co-workers have their training session booked for in the near future. All staff now have their Enhanced Criminal Disclosure checks and undergo Protection of Vulnerable Adults training within their induction period. One coworker showed the inspector various policies regarding the protection of the residents and the No Secrets document, which is also discussed during supervision sessions. Cherry Orchards does not hold any monies for the residents nor do they get involved with any personal financial issues. Residents stated, as in the previous inspection that they do not have much money to spend as they wish. This was further discussed with a manager, who said that even though the staff can sympathise with the resident, there is not much action that can be taken. Residents often have to supplement the fees with personal monies. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 17 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, 25, 26, 27, 28, 30 Residents live in a homely and clean environment within a peaceful setting. Bedrooms are large and there are numerous shared spaces enabling residents to spend time alone or with others. EVIDENCE: A tour of the property was undertaken with a co-worker. There are three main buildings on the premises where residents and co-workers live together, however, one building is being solely used for therapy sessions and meetings as management feel that the rooms are too small for residents. Guests can stay in these rooms. One of the buildings is old and presents many original features. The other two are purpose built; provide much natural light, and present a very pleasant atmosphere with lovely views. There are 18 acres of land and various outbuildings such as a barn and greenhouse. The inspector viewed one bedroom, which the resident said that it was the smallest. It was personalised and had an accessible balcony that the resident said that they enjoy. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 18 All bathrooms and toilets were entered and were found to be nicely decorated; had appropriate hand washing facilities, and were sufficient in numbers. It is recommended that the identified bathroom’s and shower room’s ceiling receive some attention, as it was damp and blackened. This was discussed with the managers and the main house has a three-year maintenance project, of which the bathrooms will be addressed. The managers said that they are planning to re-arrange the main house’s layout to be able to use the space as efficiently as possible. Residents have a varied choice of shared spaces to spend time in, both indoors and outdoors. Due to the approach of the community, areas are peaceful and serene. Outdoors lighting along the paths increases the residents’ safety and enables them to use all the spaces at all times. There are lots of plants and candles in all areas creating a delightful setting. The houses have a homely atmosphere and they were found to be clean on the day of inspection. There is a clear rota on display for cleaning chores, which both co-workers and residents spoke of and are involved in. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 19 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): 31, 33, 34, 35, 36 Residents are supported by a well-supervised staff team who provide 24-hour support within the community. The recruitment procedure has improved, further safeguarding the residents. Training details need to be provided to ensure that residents are kept safe within the home. EVIDENCE: There are five sets of permanent voluntary co-workers who live in the two main houses with the residents offering 24-hour support. Co-workers stay for a minimum of 6 months, averaging a stay to one year. Prior to the coworker’s arrival, they are made aware of their role within the home and are sent information regarding the placement. Training certificates were on display in the office; Adult Abuse Training; Basic Food Hygiene; Health and Safety for careers; Manual Handling, and Appointed Persons First Aid. However, these do not specify which staff members have completed the course. It is recommended that courses undertaken are noted within the staff files. On the day of inspection, staff were undertaking their first aid course. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 20 Recruitment procedures are followed and five staff files were looked at. Evidence of an application form; two references; terms and conditions; copies of passports and Enhanced Criminal Bureau Checks were seen. Due to many co-workers coming from abroad and new guidelines, Cherry Orchards must ensure that checks in the persons country of origin are made wherever possible for future applicants. This has been discussed with a manager. All staff have supervision sessions with either of the managers on a weekly basis in order to fully support the work they do. Managers said that they view this as an investment and to increase interactivity between all those living on the premises. As the managers also live on site, if there are any crises, then staff can reach them at any time. The co-worker further confirmed this, and also added that they also have a 3-4 monthly review with both managers and they can invite another co-worker and/or resident to gain further insight into their work. A co-worker spoke very positively about the support they all gain from each other and the managers. One manager confirmed that both managers have regular and frequent supervisions with an external therapist due to the their role of carrying out therapy sessions. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 21 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, 38, 39, 40, 41, 42 Cherry Orchards is a well-run community. Areas of health and safety and quality assurance are in need of development to further safeguard the residents. EVIDENCE: The inspector met both managers on the day of the inspection. Both have a history of experience in working within this environment and are therapists. There is a council of management with six members, and three co-opted members. As noted throughout this report, residents and co-workers are actively involved in many aspects of the running of the home. This provides an open and inclusive environment. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 22 Cherry Orchards’ quality assurance system is in need of improvement. Monthly Regulation 26 visits are not as informative as they could be and are not sent to the Commission regularly. The inspector will send details of how they can be improved. The managers said that they do give feedback forms to residents who have ceased their time at the home but do not get a lot of response. It is recommended that these forms are used throughout the placement. This was discussed with the managers. The Mental Health Foundation have recently undertaken a large research project and the home is awaiting the report. It was requested that a copy be sent to the Commission. Records are kept in the office, which is separate to other buildings. They are organised and the office is kept locked when not in use. Records needing updating and/or development were discussed with the managers. It was evident that residents are also involved in the information held about them. Policies and procedures were not looked at in depth and will be a focus of the next visit. However, the inspector viewed the record keeping; risks; verbal/physical aggression; manual handling and accidents; and whistle blowing policies. These are given to staff within their induction and are further discussed during supervisions. A co-worker had said that there is not a great emphasis upon policies due to the nature of the community. There were some generic risk assessments relating to safe working practices such as the hot water taps; fires in the kitchen; burns, and cuts. However, as discussed with the managers, development of this area, such as manual handling risk assessments, would enhance the safety of the residents and staff, (refer to standard 42.2 and 42.3 of the National Minimum Standards). The fire book was examined. Avon Fire Brigade visited the site in November 2005 and stated in the letter that “the premises were found to be satisfactory”. The fire alarms are tested weekly by a co-worker for each of the three buildings. Emergency lighting and smoke detectors have recently been installed by an external contractor and a further check has been carried out. A different external contractor checked fire extinguishers and fire blankets in November 2005. The logbook indicated that regular checks of fire fighting equipment; emergency lighting; and fire drills are only carried out within ‘Caspar House’. These checks must cover all three buildings and must cover all aspects of fire safety to ensure compliance with fire safety regulations. The candle workshop had separate health and safety rules. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 23 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 3 3 2 X Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4a,b,c) Requirement Risk assessments to be in place to minimise all risks to residents. Residents who self medicate to have risk assessments in place. Timescale for action 31/03/06 2. 3. 4. YA20 YA39 YA39 13(2) 31/03/06 31/03/06 31/03/06 24(1a,b)(3) Improve the quality assurance system. 26(1,3,4,5) Monthly visits are to be carried out consistently and copies sent to the CSCI. 5. YA42 23(4c) Ensure all areas of the 28/02/06 community are checked for fire risks and drills are carried out in all buildings to comply with fire safety regulations. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 25 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. 3. Refer to Standard YA6 YA24 YA35 Good Practice Recommendations Individual programmes (past and present) are kept in the care files. Identified bathroom and shower room ceiling to be repaired. Individual staff names are detailed on training certificates or noted within their staff files which training they have undertaken. Cherry Orchards Camphill Community Ltd DS0000026530.V276583.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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