CARE HOMES FOR OLDER PEOPLE
Goodwood Orchard 304 Uppingham Road Leicester Leicestershire LE5 2BE Lead Inspector
Keith Williamson Unannounced Inspection 12th October 2005 09:30 X10015.doc Version 1.40 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 Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 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 Older People. 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. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Goodwood Orchard Address 304 Uppingham Road Leicester Leicestershire LE5 2BE 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) 0116 2766239 Mr David Boulton Mrs Carole Boulton Mrs Carole Boulton Care Home 18 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (18) Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service User Categories DE(E) & MD(E) No person who falls within categories/combined categories MD(E) or DE(E) may be admitted to the Home when 8 persons of combined categories MD(E) DE(E) are already accommodated in the Home 11-05-05 Date of last inspection Brief Description of the Service: Goodwood Orchard is a tastefully extended house and provides an eighteen bedded home for Older Persons and Older Persons with and/or Dementia/Mental Disorder. It is sited back from a main road, and has the benefit of a large car park; and is served with a regular bus service into the City Centre. The local facilities, including shops are approximately a tenminute walk from the home. Accommodation is on both the ground and first floor. The ground floor offering two lounges and a dining room, with bedrooms being sited on the ground and first floor. Bathing and toilet facilities are sited on both floors. Goodwood Orchard has a large rear garden, with an aviary, seating for service users and mature trees and shrubs creating a peaceful and tranquil setting. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took four hours to complete. The outcome of this inspection was very positive Residents spoken to indicated that they feel safe residing in the home and that they are well taken care of. Staff members spoken to indicated that they are adhering to safe work practices in the home. A chance was taken and the inspector looked at policies and procedures, talked to residents a relative and staff. A tour of the premises took place, which indicated that the premises are maintained to a very high standard creating a homely environment for residents. Some areas of the premises were being refurbished at the time of this inspection; this created a positive atmosphere in the home, as the residents enthused as to how the improvements would look on completion. What the service does well: What has improved since the last inspection?
Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 6 The medication process was being managed more appropriately, the comments from the last inspection being acted on quickly by the manager and staff. Other issues developed by the manager and staff group since the last inspection includes changes to the daily recording system and risk assessments for residents requiring transport by wheelchair. The lounge to the ground floor has been redecorated and car parking area has been tidied, with the addition of screening for the waste bins, further work is planned to create a small flowerbed in this area. Four of the six recommendations from the last inspection report have been actioned, with the final two well into the planning stages. 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. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Resident’s privacy and dignity is recognised and upheld by staff. EVIDENCE: Staff were observed inter reacting with residents in a positive way, staff were observed knocking on a bedroom door and waiting to be invited in, by the resident. Residents spoken with indicated staff were “friendly and polite”. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents are assisted in making positive choices in the home; this gives residents the feeling of fulfilment and inclusion in the home. EVIDENCE: Residents are assisted in making informed choices by good care planning and staff communication. Residents, who have the capacity, continue to control their own finances. Some residents assisted in a recent choice over the décor of a lounge area. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 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. Residents are protected from abuse by a well informed staff group. EVIDENCE: Residents commented they felt safe in the home. Staff are trained and informed on the adult protection process, as part of the ongoing staff development. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. The home is clean, hygienic and pleasant in appearance, which creates a homely environment. EVIDENCE: The staff group have a good awareness of protecting residents from cross infection and cross contamination by the appropriate use of protective clothing. The policies and procedures assist the staff Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28. Residents are protected by a well trained and knowledgeable staff group. EVIDENCE: The manager promotes staff training and development within the home, a number of staff have completed their National Vocational Qualification Level 2 award and have commenced level 3. Due to recent changes in the staff group, the home has dropped below the required 50 of trained care staff, required by the present legislation. The manager has taken positive steps to alleviate the situation. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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 & 35. The management approach promotes effective care practice in the home for residents’ care and protection. EVIDENCE: The current manager has almost completed her National Vocational Qualification Level 4 award. No monies are currently held by staff on behalf of residents in the home. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X X Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 16 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. 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 3 4 5 Refer to Standard OP29 OP29 OP37 OP37 OP37 Good Practice Recommendations It is strongly recommended that the statutory training for staff in the home be regularly updated. It is recommended that a training matrix is used to convey what outstanding training is necessary for each member of staff, and this is completed on an annual basis. It is strongly recommended that hot water signs be placed appropriately at wash hand basins in the home. It is strongly recommended staff test and record the temperature of the shower prior to residents using it. It is recommended that all hot water outlets accessible by residents in the home are risk assessed and any remedial action taken accordingly. Goodwood Orchard DS0000006308.V256772.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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