Inspection on 05/07/05 for Goodwood Orchard

This inspection was carried out on 5th July 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

Goodwood Orchard 08/01/09

Goodwood Orchard 19/04/07

Goodwood Orchard 12/10/05

Goodwood Orchard 27/09/04

Goodwood Orchard 24/05/04

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

CARE HOMES FOR OLDER PEOPLE Goodwood Orchard 304 Uppingham Road Leicester Leicestershire LE5 2BE Lead Inspector Keith Williamson Unannounced 5 July 2005 at 8.40am 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 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 C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Goodwood Orchard Address 304 Uppingham Road Leicester Leicestershire LE5 2BE 0116 2766239 0116 2766239 None Mr David Boulton 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) Mrs Carole Boulton Care Home 18 Category(ies) of OP Old Age - 18 registration, with number DE(E) Dementia over 65 years of age - 8 of places MD(E) Mental Disorder over 65 years of age - 8 Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 person of combined categories MD(E) DE(E) are already accommodated in the home. Date of last inspection 27/9/04 Brief Description of the Service: Goodwood Orchard is an eighteen bedded home for Older Persons and Older Persons with and/or Dementia/Mental Disorder. It is sited back from a main road, which has a regular bus service into the City Centre. The local facilities, including shops are approximately a ten-minute journey. 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 sited on both floors. Goodwood Orchard has a large rear garden, with seating for service users and mature trees and shrubs. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took six hours to complete. The outcome of this inspection in general was very positive. However the providers must ensure that the medication process is followed correctly for the protection of residents in their care. 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, it is recognised by the registered person, that some areas of the premises are in need of refurbishment though this is well documented in the maintenance and improvement plan for the home. What the service does well: What has improved since the last inspection? There were eight requirements and five recommendations from the last inspection; these have all been successfully completed. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 6 The areas that these covered were the statement of purpose and service user guide; areas of staff training and information, care plans, medication and health and safety information. 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 C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 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 standard(s) 1, 2, 3 & 6. The admission procedure is good. Detailed information is provided for residents and their relatives about the services provided in the home. This home does not provide intermediate (rehabilitation) care. EVIDENCE: Detailed examination of the Statement of Purpose indicated that the document gives an accurate description of the services provided in the home. No residents spoken with could indicate that they were given copies of this document. Two residents’ files were inspected and conversation held with the residents indicated that the content of their assessments confirmed accurately their care needs, copies of the residents’ terms and conditions or contracts were also enclosed. The residents or representative receives a copy of the statement of purpose, service user guide and contract. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 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 standard(s) 7, 8, 9 & 11. Residents’ care plans are written in detail to give staff members clear instructions about the tasks they must carry out to meet residents’ care needs, which include residents having access to health care provisions. The medication procedure works well in general but is less effective in other areas, which have the potential of placing residents at risk. EVIDENCE: Detailed inspection of two residents’ care plans indicated that all aspects of personal and health care needs are being met. Comments from a resident indicated, “the staff are very good (caring) and a relative added how satisfied he was for the care his wife receives after a number of admissions prior to this home. One resident indicated that access to health care was assisted by the staff. The daily care records were inspected, the manager and inspector discussed ways to increase the detail in record and report writing by the care staff. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 10 Of the medication system, most records are accurate; though some records require a greater attention to detail the inspector has recommended attention to certain areas of the recording system. It was noted in the care plans that were seen, the final wishes of residents have been recorded. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 11 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 standard(s) 12, 13 & 15. Giving residents’ choices over their daily lifestyles and providing a wellbalanced meal is managed very well for residents residing in the home. EVIDENCE: Two residents were spoken with and they indicated that they are satisfied that they have choices regarding their daily living routine in the home. One resident was observed to indicate their preference to eat her meal in her bedroom; the staff were noted to assist with this choice. Detailed examination of the weekly menu indicated a clear choice of meals; the inspector witnessed the choice of main meal offered to residents immediately prior to the time it was served. Two residents and a resident’s relative spoke positively about meals provided in the home. One resident commented “I think the food is good”. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 12 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 standard(s) 16. Residents are well protected by having information about the complaints procedure. EVIDENCE: The complaints procedure is publicly available in the home, and is also available to all residents and their families through the service user guide. The manager and inspector discussed a complaint, which shall be recorded by the home, the outcome being satisfactory. No complaints have been forwarded to the Commission for Social Care Inspection. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 13 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 standard(s) 19, 20, 21 & 25. The premises are maintained to a very high standard with strong emphasis on residents’ comfort. There is sufficient communal space including adequate numbers of toilet and bathing facilities. The home is very clean and pleasant in appearance. EVIDENCE: An inspection of the flooring, walls and fixtures in the home indicated that the providers make good effort in maintaining the home to a good standard. Two residents spoke positively about the upkeep of the home. One resident commented “I’m very happy with my room” (referring to her bedroom). Bedrooms viewed throughout the home were noted to be personalised, bright and airy. The bathroom and toilet facilities were inspected and found to be sufficient in numbers based on the number of residents residing in the home; the manager and inspector discussed the re-decoration and change of use of a room. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 14 Risk assessments were noted to be in place, of the first floor windows and radiators in the home, these were requirements at the last inspection. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. The care hours and staffing numbers provided in the home are sufficient for the provision of residents’ care and protection. Suitable training opportunities are given to staff members to enhance their specialised skills and knowledge. EVIDENCE: The staffing rota was examined and a physical count indicated that there was an adequate number of care staff on duty. The staffing rota was seen and discussions held with the manager indicated that there is appropriate skill mix of staff employed to work in the home, however a number of staff have yet to complete what is recognised at “statutory” training, the manager indicated this would now be seen as a priority. Residents spoken to indicated that there are staff members available when needed. Staff files were viewed and the staff appointed have the appropriate preemployment checks in place. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 & 38. The management approach promotes effective care practice in the home for residents care and protection. EVIDENCE: Discussions held with two staff members and three residents indicated that the management approach creates an open and inclusive atmosphere in the home. Minutes of residents and care staff meetings were seen, and the results from a recent resident survey were also viewed; the manager stated these findings shall be made public, and be added to the next revision of the service user guide. Staff supervision and appraisals have commenced in the home, the manager is aware of the need to delegate some of these tasks to senior care staff. Fire records and other health and safety documents were examined and were found to be in order. A member of staff indicated that the home appeared to be adhering to safe work practices for example the practice of safe moving and handling techniques, however there are a number of residents who have yet to Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 17 have risk assessments completed with a view to being moved and handled safely. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x 3 x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x 3 x 3 Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 19 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. 3. 4. 5. 6. Refer to Standard 7 9 19 29 29 38 Good Practice Recommendations It is recommended that a numbering system is used to convey what issues of the care plan have been accomplished for each resident in the home, each day. It is recommended that all medication is returned each month, and periodic stock checks of medication is made to ensure safety of residents in the home. It is recommended that the maintainance plan for the home is projected forward, and kept in such a way that tasks completed are recorded on a regular basis. It is strongly recommended that the statutory training for staff in the home, is regularly updated It is recommended that a training matrix is used to convey what outstanding training is neccesary for each member of staff, and this is completed on an annual basis. It is strongly recommended that risk assessments be completed for all residents requiring wheeled transport in the home. Goodwood Orchard C51 S6308 Goodwood Orchard V225907 110505.doc Version 1.30 Page 20 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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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