Inspection on 16/02/06 for Orchard Blythe

This inspection was carried out on 16th February 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orchard Blythe 18/06/07

Orchard Blythe 07/08/06

Orchard Blythe 27/09/05

Orchard Blythe 06/01/05

Orchard Blythe 01/07/04

Orchard Blythe 29/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Orchard Blythe Orchard Blythe HEP Wingfield Road Coleshill Birmingham West Midlands B46 3LL Lead Inspector Yvette Delaney Unannounced Inspection 16th February 2006 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 Orchard Blythe DS0000041996.V284392.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 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. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Orchard Blythe Address Orchard Blythe HEP Wingfield Road Coleshill Birmingham West Midlands B46 3LL 01675 467027 01675 467027 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) Warwickshire County Council Mrs Michelle Bernadette Wilson Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Orchard Blythe is a Local Authority home for older people. It provides 25 permanent care beds, 5 beds for people on short stays, and 5 beds for assessment purposes. The home is situated very close to the town centre of Coleshill, next to a primary school. There are a few local shops within fifty yards, and Coleshill High Street is within easy walking distance for a mobile service user. There are parking spaces to the front of the home. Orchard Blythe’s accommodation is all on one level. It is divided into three units, two wings are for permanent service uses, and one wing used for short stay purposes. There is a very large reception area, which is used by service users to socialise and to participate in therapeutic activities. There are three staff offices, a hairdressing room, a kitchen (with its own staff room and WC) and a laundry. In addition, there is a day care lounge for ten people. All bedrooms have en-suite lavatories and wash hand basins. There are four communal bathrooms with assisted bathing facilities and WCs, and one separate WC. There is a staff room with a WC and a shower. The home is staffed over 24 hours. The management team consists of a registered manager; assistant manager and four care officers. A part time clerical officer provides administrative support to the management team. There are care assistants, providing care during the day and night. In addition to care staff are domestic staff, cooks and assistant cooks. The home does not provide nursing care. Service users who require nursing attention receive this from the community nursing service, as they would in their own homes. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on a weekday between the hours of 11.30 am and 20.00 pm. This was the second visit for this inspection year. The Home Manager and Deputy Manager were present at this inspection. Staff in the home co-operated fully with the inspection. Managers and staff were proactive in their response to the inspection and were keen to improve practices and the environment to ensure that residents’ needs are met. The inspection process involved discussions with the managers, examining care plans, case tracking, discussions with staff and residents. Records related to residents, staff, the environment and operations in the home were examined. These include maintenance, servicing contracts, care profiles, accident records and policies and procedures. Details in a pre-inspection questionnaire sent to the home prior to the inspection provided factual information on the home. Comment cards sent to the home and given to residents and relatives also informed this report. Fourteen comment cards were received from residents and six from relatives. Their views are detailed in the following table: Outcome of Service Users Comment Cards – 14 received Yes 14 14 14 13 6 6 10 14 10 3 No Sometimes Comment 1 2 3 4 5 Do you like living here? Do you feel well cared for? Do the staff treat you well? Is your privacy respected? 1 No response 8 5 4 2 11 1 1 3 No response Do you wish to be more involved in decision making within the home? 6 Does the home provide suitable activities? 7 Do you like the food? 8 Do you feel safe here? 9 If you are unhappy with you care do you know who to speak to? 10 Do you or a relative or representative wish to speak to an Inspector about your life in the home? (If so tell us your name) No comments received Outcome of Relatives/Visitors Comment Cards – 6 received Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 6 Yes 1 2 3 4 5 6 7 8 9 Do staff/owners welcome you in the home at any time? Can you visit your relative/friend in private? Are you kept informed of important matters affecting your relative/friend? If your relative/friend is not able to make decisions, are you consulted about their care? In your opinion are there always sufficient numbers of staff on duty? Are you aware of the home’s complaints procedure? Have you ever had to make a complaint? Are you made aware of forthcoming inspections? Do you have access to a copy of the inspection reports on the home? 6 5 4 4 3 2 1 1 2 No No Comment 1 1 2 4 5 5 2 1 Not applicable 1 Not applicable 1 Not applicable 1 Usually 1 Have not asked 1 Question mark 10 Are you satisfied with the overall care provided? Comments: 5 1 “Very satisfied” “…comes in for one weeks respite at a time, we don’t visit and so most of these questions do not at present apply.” “Staff always very caring, helpful and kind and very supportive. When I made a complaint (too strong a word) it was dealt with immediately. It is very difficult to assess what would be the best ratio of staff to residents.” “My sister and I are more than satisfied with the care and help given to my mother. The staff are a great team who are always cheerful and helpful.” “I am not notified if he has a fall or if he has to go for glasses or Dentist. My father’s memory is failing and does not remember where he has been. Father stays in bed a lot. He has a history of breakdown and depression but no one bothers.” Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 7 What the service does well: What has improved since the last inspection? What they could do better: • Care planning needs to be improved to ensure that they detail the current needs of residents at all times and instruct staff on how to meet these needs. Risk assessments related to resident’s care, which include nutrition and falls needs to be improved to clearly demonstrate the criteria used to carry out the assessment, verifies the outcome and identifies the preventative measures required for individual residents. Staff training needs to be brought up to date, to include increasing the number of staff with at least an NVQ 2 qualification, ongoing attendance at training related to the care of residents living in the home and update attendance at mandatory training sessions. • • 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. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 8 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 Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 9 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): 2, 3, 4 and 5 Each resident has a written contract of terms and conditions of the home, which ensure their human rights. The residents’ needs are assessed before admission and residents and their families are reassured that their needs will be met. All residents and their families are invited to visit the home prior to admission giving them the opportunity to assess the quality of facilities and suitability of the service offered. EVIDENCE: The home provides residents with a statement of terms and conditions. A contract of residency is completed for all residents, which details the terms and conditions for living in the home. Details of the fees payable and by who (service user, local or health authority, relative or another) are included in a separate document. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 10 Orchard Blythe is a Local Authority owned care home and pre-admission documentation examined demonstrates that all residents have their initial care needs assessed by social services. This assessment is then followed with an assessment carried out by the manager of the home to ensure that the home has the resources to meet the needs of the potential resident. Records viewed and discussion with staff confirmed that staff had undertaken some mandatory and specialist training, which would support them to meet the needs of residents admitted to the home. One resident spoken to stated that the decision to move into the home was based on advice from a social worker and the fact that they had previously attended the home for respite and day care. Residents spoken with made positive comments about the quality of care and the conduct of the staff, comments made include, “happy with my care” “staff are always caring and helpful’’ Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 11 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): 7, 8, 10 and 11 Residents’ health, personal, social and health care needs are set out in individual care plans, current care needs are not regularly updated, which may result in an oversight of care and poor or inconsistent care provision. Residents’ right to privacy and dignity is upheld leading to a feeling of being valued and respected in the home. The lack of written information does not confirm that the period leading up to a residents’ death and the time of their death is treated with respect and sensitivity. EVIDENCE: Three care plans were examined these demonstrate that improvement had been made in the way they had been completed. Information, which identifies individual residents health, personal and social care needs is available with details of action to be taken by staff to meet these needs. However care plans were not updated in a timely manner to reflect the current needs of residents. Care plan documentation identifies the needs of residents based on the activities of daily living. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 12 A care plan for a resident whose health had deteriorated rapidly (over a period of two weeks) had not been updated to reflect the recent care needs and the action to be taken by staff to meet these needs. In the care review documentation for this resident it was written that they use a stick to aid mobility. Instructions to staff were to monitor and record any changes in mobility and encourage continued use of a walking stick. Written daily care statements for the period of the residents deterioration identified that the resident was confined to bed and care plans had not been updated to reflect this. The review further states that the resident was eating small amounts of food. Daily statements identified that they were only taking small amounts of fluid. The overall care plan is stated as written on 28 June 2005 and due for review on 23 February 2006. The most recent review of the care plan was available on a separate form titled ‘Monthly Review of Service Plan.’ Cross-referencing both documents did not confirm that all changes had been transferred to the main care plan. There was evidence in written daily statements that the resident’s needs had changed with increasing deterioration in their physical well being. Care plans were not updated to reflect these changes. Daily statements do not give an immediate picture of residents’ 24-hour day as separate night records are maintained. Statements written by night staff to reflect the type of night had by residents were examined entries state ‘all checks as per PS68.’ Examination of the form demonstrates that all residents’ names are detailed on one form and initialled by care staff to indicate check made. The completion of the form in this way did not observe confidentiality and data protection. There was no indication on the form as to what the check involves. A separate procedure examined details generic night routines used by all Warwickshire County Council homes (WCC) with no clear indication of what the checks were carried out for individual residents. When completing daily statements spaces are being left following each entry. Staff are scribbling out entries instead of crossing through once and initialling and unexplained abbreviations are being made. Risk assessments have been undertaken and include the prevention of falls and nutritional risk screening with regular weight checks. The initial nutritional assessment for one resident did not give an accurate account of their risk potential at admission. The criteria used for assessing the risk of falls were not clearly identified. The date on some risk assessments did not demonstrate that they are regularly updated. Examination of three residents’ care plans viewed found evidence that residents have access to a range of specialist health care services including chiropody, dental, sight and hearing checks. Pressure relieving cushions, hospital beds and mattresses are available for residents who are assessed by Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 13 the community nurse as being at risk of developing pressure sores. Residents spoken with confirmed that they were able to register with a General Practitioner (GP) of their choice, providing the GP was in agreement. Staff addressed residents in a respectful manner and called them by their preferred name. One relative stated that the staff were always caring and friendly and was happy with the care given. Policies and procedures are in place for handling dying and death. A statement written by night staff in reference to a recent death in the home demonstrates that the time of the resident’s death was treated with sensitivity and respect. Examination of care plan documentation did not demonstrate that discussions had taken place with residents or their family regarding their wishes and/or arrangements after death had occurred. There was also no evidence of consultation with residents to establish and record their wishes in the event of a life limiting illness. Care plans had not been updated to include information about the wishes of residents and their families during the time they are dying and during their death. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 14 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): 12, 13, 14 and 15 The lifestyle in the home related to social, cultural, religious and recreational interests result in an acceptable level of well being for residents. Residents are encouraged and supported to maintain contact with their family, friends and the local community resulting in supporting their social skills and increase in their mental well being. Residents are encouraged and enabled by staff with the support of their family to exercise control over their lives resulting in increased self-esteem and quality of life. A varied and nutritious choice of foods is offered by the home in consultation with residents’. EVIDENCE: One of the residents spoken with spoke about the basket weaving she had done and showed the inspector a valentines card she had made in craft sessions held at the home. Monthly activity programmes examined showed a range of activities, which include bingo, which occurs at least three times per week, trips to garden centres where residents also had lunch, creative mobility, karaoke and quiz nights. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 15 Relatives, friends and other visitors are encouraged to visit throughout the day and maintain contact and involvement in the care of their relative. Visitors were observed to visit the home at the time of inspection. Links are established with the local community. On the evening of the inspection a resident spoken to was waiting for transport to take her to a local community club, which she routinely attends. Residents were easy to talk to and obtain their views on living in the home. Residents were seen to be relaxed, smiling and happy to be living in the home. Eleven residents were spoken with comments made were positive and highlight a trust in the staff looking after them. The inspector ate lunch with the residents this consisted of lamb stew, carrots, parsnips and potatoes an alternative choice of battered roe was also available. A choice of desert was available homemade egg custard, fruit or cheese and biscuits. Residents said that they enjoyed their meal and ate well. Residents are very sociable and conversations were taking place as they sat in small groups around the dining tables. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 16 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): 16, 17 and 18 The home has a clear and easily accessible complaints procedure, which indicates an open and positive approach to problem solving. The service ensures that resident’s legal rights are protected and have systems in place to protect them. Policies and procedures concerning the protection of vulnerable people are adequate but the absence of attendance by staff to ongoing adult protection training does not support the service in ensuring that residents are protected from abuse. EVIDENCE: A complaints policy/procedure is available in the home and was available for examination. Records of all complaints received in the home are maintained. There is currently one complaint that has recently been responded to addressing concerns related to falls. The outcome of the investigation has been forwarded to the complainant. Residents spoken with were not all aware of the complaints procedure, but told the inspector that they would have no hesitation in raising any issues should they have cause to complain. Residents are encouraged and supported to exercise their legal rights. Access is available to advocacy services and leaflets/notices are available informing residents and visitors of the facilities available. Some residents have their relatives supporting and acting on their behalf when exercising their legal rights. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 17 Due to recent events related to the inappropriate response by staff following concerns of possible adult abuse, staff have been instructed to confirm that they had read the policy and procedure for the local authority. Policies and procedures in place are aimed at protecting residents from any risk of abuse. There was no evidence that staff had received recent or an update in the protection of vulnerable adults. Two staff spoken with gave a good account of the action they would take should they have cause for concern. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 18 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 and the review of standards of hygiene and practices in the home ensure that changes are made to minimise the risk of infection. EVIDENCE: A tour of the premises found the home was free of offensive odours and kept clean and hygienic. There is a policy/procedure on infection control. Laundry is washed at appropriate temperatures to thoroughly clean linen and control any risk of infection. Bins have been provided in residents’ en-suite facilities. Pedal bins are to be provided in all areas of the home to minimise the risk of cross infection. Plans are to install shelving in the en-suites for the storage of pads. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 19 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): 27, 28, 29 and 30 The numbers of staff during the day of inspection were sufficient to meet the needs of residents accommodated in the home, which should lead to appropriate care provision and support an increase in the quality of life of individual residents. The skill mix of staff on duty on the day of inspection meets residents’ needs, ongoing training is needed to ensure that this level is maintained at all times. The procedures for the recruitment of staff are robust to ensure that all safeguards are accessed to offer protection to residents living in the home. Staff were observed to be competent to do their job but training is not up to date, which could result in inappropriate care being given and deterioration in the quality of life for individual residents. EVIDENCE: There remain two carers on night duty for 35 residents. Documentation available identifies that night care staff carry out laundry and allocated domestic duties. The Inspector was advised that these duties are only carried out if there is time and residents take priority. Staffing levels are also reviewed dependent on the needs of residents. Training records demonstrate that there are currently 15 of 38 (39 ) care staff, which includes the managers of the home with an NVQ qualification. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 20 Four staff files were examined. Records were found to have been reviewed to ensure they contain the range of statutory pre employment checks required to establish staff fitness. Security checks, which include Criminal Record Bureau (CRB) Checks, had been undertaken for employees. All personal record files inspected held copies of terms and conditions. Evidence was available to confirm attendance at training sessions related to care topics. Training was not recent but would help to support staff to meet the needs of residents accommodated in the home. These include Dementia care, medicine administration, MRSA and palliative care. Training records examined show that statutory training is not up to date; this includes fire, which should be provided twice per year, moving and handling, health & safety and food hygiene. Records examined providing details on induction training for new staff indicate that the contents meet the National Training Organisation targets. Examination of documentation found that staff complete induction training within 12 weeks of appointment to their posts. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 21 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): 33, 36, 37 and 38 The home has a quality system, which looks at the quality of care and informs improvements in the home for residents. Supervision procedures have been implemented to monitor care practices delivered by individual staff and ensure that residents’ health, safety and welfare is maintained at all times. Records are organised, accessible and securely stored, which should safeguard residents’ rights and best interests. Observation and examination of records indicates improvements to health and safety practices in the home, which will safeguard and protect the interests and welfare of residents. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 22 EVIDENCE: The home has some quality monitoring in place, which involves surveying residents and relatives on the quality of care and services provided. Quality cycle meetings are held in the home and chaired by an independent person. Minutes are maintained topics covered include attitudes of staff, residents’ complaints and suggestions, meals and activities and outings. Monthly reports detailing the outcome of visits made by the responsible individual provides information on the quality of services provided in the home. The Commission receives copies of these reports. It was established through discussion with the managers and examination of staff files, that there is a formal system of supervision of staff in the home. Care staff said that they are receiving supervision and one member of staff was receiving supervision on the day of inspection. Individual residents records and other personal confidential information related to staff and residents are secured in locked cabinets, in the manager’s office. Computers in the home are password protected. Maintenance checks being carried out include checking of fire alarms and fire doors for closure and the emergency lighting. Water temperature and valve checks were made to ensure that water was being delivered at a safe temperature. It was evidenced through maintenance records and contracts that all equipment and appliances used in the home include hoists. Data sheets related to the Control of Substances Hazardous to Health are available in the home. Service contracts and information related to equipment and ongoing maintenance in the home was. Policies and procedures examined include ‘Missing Service Users.’ The document provides detailed guidance for staff on what action to take if a resident goes missing from the home. An additional amendment has been added due to a recent incident where a resident went missing. The amendment describes additional security measures to be taken by staff. The risk assessment related this procedure has also been reviewed to include further information on prevention. Orchard Blythe DS0000041996.V284392.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 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 3 3 Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15, 13, S.3 Requirement Timescale for action 30/04/06 2 OP7 15 S.3 3 OP7 15 S.3 4 OP7OP8 17 15 14 17 S.3 S.4 The registered manager must ensure that care plans are up to date and address the needs of the residents and are related to up to date clinical guidelines. The registered manger must 30/04/06 ensure that care plans are evaluated monthly or more frequently if needed and changes to care needs are clearly indicated. The registered manager must 30/04/06 ensure that the care planned reflects the actual needs of the residents and when changes occur these are clearly indicated and new plans developed. The registered manager must 30/04/06 ensure that all residents have full risk assessments and where a risk is demonstrated an appropriate plan of prevention must be devised. These must include clear criteria for the risk assessment of falls and nutrition. Risk assessments must be assessed monthly and changes in risk factors clearly recorded. Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 25 5 OP7OP10 12, 15, Sch3 6 OP28 18(1)(a) Care plans must reflect the actual needs and care to be given to residents who are dying and at the time of their death. Daily reports must contain details of the care given. The registered provider is required to devise an action plan detailing the arrangements for ensuring that at least 50 of care staff have a NVQ Level 2 or equivalent and shall submit a copy of the action plan to the Commission. Outstanding from inspection dated 6 January 2005. The Registered Manager must ensure that all staff are up to date with Statutory training requirements and attend training related to the care of residents living in the home. 30/04/06 30/04/06 7 OP30 18(1)(c) 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Orchard Blythe DS0000041996.V284392.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!