CARE HOME ADULTS 18-65
Orchard Close (2&3) 2 & 3 Orchard Close Rodney Road Wanstead London E11 2DH Lead Inspector
Stanley Phipps Unannounced Inspection 22 August 2005 15:45 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Orchard Close (2&3) Address 2 & 3 Orchard Close, Rodney Road, Wanstead, London E11 2DH 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) 020 8518 8261 Redbridge Community Housing Limited (RCHL) Mr John Troy CRH Care Home 16 Category(ies) of MD Mental Disorder (16) registration, with number of places Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To include one named person over 65 years of age. Date of last inspection 10 March 2005 Brief Description of the Service: Orchard Close (2&3) is a care home providing personal care and accommodation for up to sixteen adults (52-87) with mental health support needs.The home provides a service to both men and women.The service is owned and managed by Redbridge Community Housing Limited. The home is located in a quiet residential area of Wanstead in the London Borough of Redbridge and is also close to some small local shops and a bus route.The home was opened in March 1991 and comprises two houses that are adjacent to each other, but managed as one service. The houses consist of a total of twelve single and two double rooms. The home is supported by staff on a twenty-four hour basis that work closely with service users in developing their personal/living skills, confidence and self esteem by increasing their presence in community living. It is run by a very experienced manager and deputy; and two senior support workers, one based in each house. Orchard Close is geared towards enabling each service user to access healthcare, leisure, spiritual and recreational pursuits in line with their individual choices. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place in just over five hours and was timed to coincide with meeting service users who may have been out in the day, assessing the evening activities, including the evening meal and to monitor the service. The inspection found that there have been improvements to the service since the last inspection, but there is still some work to be done in improving the service and satisfying the national minimum standards for younger adults. On the day of the visit an Immediate Requirement Notice was served, as the cupboard (House 2) containing substances under COSHH was not lockable at the time of the visit. This placed service users at risk. This failing was rectified within seven days of the notice being served and the registered manager notified the Commission in writing about the action he had taken. An assessment of the policy and procedures’ file, menus, a random sample of service users’ plans, the staffing rota and activities for service users was undertaken. Three service users were spoken to and detailed discussions were held both with the manager and three other of the support staff on duty. This was followed by a tour of the building to include a service user’s bedroom. What the service does well: What has improved since the last inspection?
There was evidence to confirm that all improvements to the environment, identified at the last inspection visit were carried out and two service users spoken to were happy with the quality of the repairs carried out in the home. The organisation has produced a training manual that was specific to the training requirements of its staff, who felt that this was a positive outcome in relation to their professional development. This also means by extension that service users would receive a higher standard of care, once this training is implemented.
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 6 The registered persons were also successfully involved in seeking alternative placements for two of their former service users whose needs had changed to the point where Orchard Close could no longer meet them. It must be stated that the transitions did require consistent work from the management and staff team at Orchard Close to achieve the best possible outcomes for the service users concerned. Improvement was noted in the area of maintaining records required by regulation for the protection of service users. Although there is some way to go to fully meet the standard, things have improved. The manager explained that between the deputy and himself, the records are evaluated regularly. On examining food storage in the home, it was clear that efforts were made to safely store food, generally and in the fridge. In essence there was improvement, but further improvement was require to fully meet the standard thereby ensuring that risks to service that are associated with unsafe food storage are minimised. What they could do better:
Some of the areas for improvement were discussed with the manager, while others were discussed with the various members of staff on duty in both houses as the manager was there for a part of the inspection only. Amongst the areas identified was for the staff vacancies in house three (3) of which the manager informed that there were up to three posts to be filled. He further advised that these posts were currently covered by the use of bank shifts. Whilst this is fairly satisfactory practice, it is important to ensure that staff are permanently recruited to those vacant positions. This would benefit service users as permanent staff would offer greater consistency through e.g. key-working and the training provided by the organisation. More could also be done to improve how the changing needs of service users are reflected in their service user plans and this includes changes to risk assessments conducted on service users. In a random sample of service user plans examined, there was at least one case in which this information was not satisfactorily maintained. As part of observing how service users are empowered and their rights respected in daily life in the home, it was clear that staff had various ways of interacting with service users to achieve agreed outcomes. However it must consistent that all service users are treated with dignity and respect at all times in interventions made by staff to achieve those outcomes. There was no doubt that the views of service users are sought on a daily basis in the service either through informal discussions, key-work sessions or the organisation’s quality audit of the service. Evidence of this audit (dated April 2005) was sent to the Commission on 18/10/05. However it was evident that there has been a lack of consistent monthly provider monitoring visits as required by regulation, conducted by the registered persons, to assess how effectively the home is achieving the aims and objectives, as set out in their Statement of Purpose. This must be improved. With regard to the management of the service, this has been generally satisfactory but more needs to be done to ensure that the health and safety of service users are promoted at all times. The areas of weakness are specifically
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 7 identified in the main body of this report under the ‘Conduct and Management of the Home’ standards. 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 Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 9 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 standard(s) (1,2) Service users can be assured that information about the home that is contained in the statement of purpose for the home is reflective of the service they receive and this includes a detailed assessment of their needs prior to admission to the home. EVIDENCE: The statement of purpose and service user guide for the home remained satisfactory and in so doing was reflective of the services and facilities provided at 2&3 Orchard Close. Although there were no recent admissions to the home it was reported that a prospective service user was under consideration. This service user would have no problems in determining whether or not the home is suitable for his/her needs as all the information regarding the service is available to the individual prior to their admission. As part of that admission process a detailed assessment is conducted by the home in determining whether or not the service user’s needs could be provided for. Satisfactory arrangements are in place, therefore to enable prospective service users to be admitted into the home. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 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 standard(s) (6,9,10) Service users are encouraged to live life to their full potential whilst living at Orchard Close and some of the main tools used to enable this are risk assessments and individual service user plans. They are used to deliver a safe and quality service. However these tools are most effective when they are kept updated and current. Service user confidentiality is appropriately maintained and this not only gives them protection, but also peace of mind. EVIDENCE: From talking to service users, observing them and viewing records, it was clear that staff work closely with them to achieve not only their personal goals, but a good quality of life at Orchard Close. There were care plans and risk assessments in place and most detailed the actions to be taken in relation to needs identified. One service user proudly spoke of his contributions to the home and this included washing up, cleaning the table and placing dishes in the dishwasher. He also confirmed that he enjoys socialising with other service users both from Orchard Close and other services. This included a recently held barbecue held at the home, which he described as ‘really good’. He also talked about attending a ‘drop-in’ where he enjoys a good game of snooker. He enjoys his independence particularly handling his finances and felt that the
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 11 staff were very supportive to him. Records viewed regarding this service user were satisfactorily maintained and they reflected what was happening with him at the time. An assessment of the file of another service user who was unwell at the time proved somewhat different in that despite her period of relapse which is cyclical, there was no evidence of a care plan review, neither was there a risk assessment available for inspection. While there is little doubt that staff may know the service user very well, the national minimum standards and its associated regulations require risk assessments and current service user plans that reflect the change in needs of all service users. The benefit of this includes current awareness of all staff, including bank staff, of action/s to be taken and this would be a benefit to the service user concerned. Staff interviewed, showed a sound awareness of confidentiality and records held on service users were securely stored. This means that information on service users is in safe hands at Orchard Close. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 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 standard(s) (11,12,15, 16,17) Service users are supported to participate in activities that interest them and this includes maintaining personal/social relationships with friends and family. Generally they are respected and empowered, although more could be done to ensure that this is maintained at all times. Nutritious meals form an integral part of a healthy lifestyle, at Orchard Close. EVIDENCE: Service users are encouraged and supported to engage in pursuits according to needs, choice and interests and this varies from service user to service user. One service user spoke of their involvement at Ley St. day centre, which they confirmed attendance as between Monday and Wednesday weekly. She described this as something she wanted to do and that the staff supported her to achieve this. She sees the hairdressers on a Thursday and goes out dancing on Fridays. She enjoys relaxing in the evenings at the home and also has the benefit of attending relaxation sessions outside the home. Other service users were pretty happy with contributing to chores around the home and undertaking their personal tasks both in their private spaces and the community e.g. tidying their rooms, personal shopping. A significant number of
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 13 the service users were over sixty–five years old and they were happy their individual routines. A good example of this is their engagement in domestic tasks, which is done on a rotation basis. This was drawn up in conjunction with staff and they are prompted and reminded when it was their turn. Staff worked well with service users to achieve their daily outcomes and this was evident on the day of the visit. All service users spoken to spoke positively of this aspect of their involvement in the home. However there was one case in which a service did not carry out his task for the evening at the time he agreed to. The management of enabling him to achieve this objective compromised both his dignity and respect, as he was spoken to openly i.e. from the bottom of the stairs, while he was at the top about his failure to carry out the task as expected. This was made worse by a reference being made to an understanding that the task gets done at a particular time whenever the staff member was on shift. Whilst the outcome was both important and desirable the process of achieving this clearly was not. For example there was no risk to the safety and/or welfare of anyone in the home because the task was not completed at the time expected. The concept of flexibility, negotiation and empowerment was not evidenced and this was brought to the attention of the staff concerned. All service users are encouraged to maintain links with their friends and family and examples of this included one service user meeting her sister weekly, while another has a visit from a personal friend. He was interviewed about his experiences, while visiting and described them as very positive. He thought that the management and staff of the home were ‘brilliant’. Food management in the home remained satisfactory and all service users spoken to were very complimentary about the quality and content of the meals in the home. One service user from Italian origins informed that he enjoys pasta and is able to eat it in the home, although he indicated that he has a love for English dishes. This confirmed that there is flexibility in the meals provided at Orchard Close. It was also evident that drinks and snacks were widely available to all service users living in the home. More could be done to improve the food storage arrangements at the home and this is covered in more detail in standard 42 of this report. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 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 standard(s) (20) Service users are reassured that they well supported in dealing with their medication, which they value as an integral part of managing the difficulties associated with their illnesses. EVIDENCE: Given the specialist needs of the service user group i.e. mental health, they at times become very distressed in managing some of their daily routines. Staff generally work closely with service users reassuring them through listening, discussing alternatives in order to diffuse their anxieties. These interventions whenever they are made are recorded in individual service user files. An assessment was undertaken of how medication was handled and this was satisfactory. The storage and recording of drugs was satisfactory. It was positive to see that the improvements in the handling of medication have been consistently maintained. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 15 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 standard(s) (22) The management of complaints in the home gives service users, staff and relatives confidence that their concerns would be addressed, whenever they are raised. The process could be enhanced by ensuring that the details of the Commission for Social Care Inspection are referred to in the complaints procedure. EVIDENCE: At the last inspection the registered manager was required to review the complaints procedure to ensure that it reflected the details of the Commission. The procedure could not be located at this visit and the staff could not be sure that the change had been undertaken. Therefore the present requirement would be repeated in this report. The complaints management in the home however remained satisfactory and service users spoken to knew who and how to make a complaint. The friend of a service user also indicated that he was aware as to what to do if he was unhappy with the way his friend is treated. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 16 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 standard(s) (24, 27,30) Service users are cared for in a clean and homely environment by and they are assured that satisfactory arrangements are in place to ensure that this is maintained. EVIDENCE: On the day of the visit, the home was clean, odour free and well maintained. Service users in both areas of the service (Houses 2 & 3) actively contributed to its upkeep through their involvement in daily chores. Their involvement is more than routine, in that it enables them to retain skills associated with the maintenance of a clean environment. All works identified from the last report were satisfactorily carried out and this included minor works to bathrooms both in Houses 2&3. Service users and a friend who were spoken to were extremely pleased with the home. Staff informed that two worn armchairs in House 3 were up for replacement and this was an indication that the system in place for renewals and replacements were satisfactory. There were no concerns with the environment at this visit in relation to the standards assessed. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (33,34,35,36) Service users benefit from having an experienced manager and staff team who work well together to enhance the quality of services they receive. Established support systems are in place for staff to enable them to provide a quality service at Orchard Close, but staffing recruitment policy and practices needs to continue in its improvement, to ensure the protection of service users. EVIDENCE: From discussions held and an interview conducted with staff, it was clear that they were well aware of their responsibilities, as defined in their job descriptions. Service users were aware of the key worker system in the home and up to three of them actually described what role their key worker plays in supporting them. Feedback obtained from service users indicated that they were generally happy with the staff team in both houses (2&3). The staff team is mixed both in terms of gender and ethnicity and this gives service users options, particularly in terms of same sex care and support. In discussion with the manager it was detailed that a number of shifts were covered using the bank system and this was a result of having three support staff vacancies in the home. The merits of having a full staff compliment was discussed with the manager with a view to recruiting to those vacancies. One such advantage to service users is that it would ensure a greater commitment
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 18 to working with them with the added benefit of specific training targeted for permanent staff. It would also make covering annual leave and other forms of short-term absence easier in that there are more numbers of permanent staff to choose from. Generally the needs of service users are both individually and collectively met, but on the day of the visit, it was questionable in House two, whether or not the individual needs of one service user was actually met. It was observed that this service user was particularly unkempt as though he was not in receipt of personal care for some time. It was established with the staff coordinating the evening shift that this was the case and subsequently the question was raised as to what was being done about it. A training profile was in place for staff and a recently produced training brochure outlining relevant training was also available for all staff. The inspector was in no doubt of the staffing ability and expertise to provide the appropriate intervention to the service user, but there was no evidence as to what action was in place to deal with it. Moreover the staff coordinating the shift informed that she had been away and had only recently returned to duty and as such she was not sure why an intervention was not made sooner. She was clear that the service user goes through these phases and is usually more responsive with male intervention. This could be improved through better communication and coordination. From a staff interview and discussions held with them, it was determined that staff were satisfied with the quality and level of support they receive to carry out their jobs. It derives mainly from formal supervision, team meetings and informal discussions. In essence service users can be confident that they are cared for by a well-supported staff team. At the last inspection, it was determined that the organisation needed to improve on its recruitment policy and practice and progress area is scheduled for evaluation on the 28/9/05. At Orchard Close the manager and his deputy was working strategically to ensure that information held on staff by the home complied with Regulation 17 Schedule 2 of the Care Homes Regulations 2001. There was noticeable improvement by the home with just two staff records not containing the full requirements of the regulation. This requirement would therefore be repeated in this report. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) (37,39,42) There are management systems in place to enable service users to receive a good standard of care at Orchard Close. This is complimented by having an experienced manager who leads in the main, a team of dedicated staff. Service users would stand to benefit if greater emphasis is placed on monitoring quality, which must be extended to health and safety in the home. EVIDENCE: There is a satisfactory framework of policies and procedures, some quality monitoring and the benefit of a dedicated staff team (evidenced by relatively low levels of sickness absence and staff turnover), which is led by a manager experienced in the field of mental health. Both service users and staff were comfortable and felt safe with the open-door style of management adopted by the registered manager and it was clear that overall there were improvements to the service since the last inspection. More needs to be done however to further enhance the quality of the service provided at 2&3 Orchard Close and an example could be drawn from the lack of consistent monthly provider visits to this service. This is an important part of monitoring the service as specified
Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 20 under Regulation 26 of the Care Homes Regulations 2001. It enables a responsible individual from outside the daily management of the home to look at quality issues regarding the service users and this includes getting a view from the service users themselves and staff on how the home is run. In the case of Orchard Close the last report on file at the home was around May 2005. This is significant break in the registered persons ability to adequately identify and follow up on issues that have arisen in the home, during that period. An example of such include the inconsistent monitoring of fridge/freezer temperatures in house two, the inadequate storage of foods again in house two and a lack of clear protocols in house three around the freezing and subsequent de-frosting of milk for use there. All items listed here have health and safety implications with service users as the group of people most likely to be significantly affected. The areas listed above were also discussed with the relevant staff in the two areas of the home. For clarity on the failings relating to storage of food, there were a number of dry food products that were found improperly covered, in House two, while with the frozen milk in House three, there was no clearly documented or established protocols for when frozen milk is defrosted, to ensure that there is minimum risk when this milk is made available to service users. This must be improved. Finally at the last inspection visit it was recommended that the registered manager liaise with the now Learning Skills Council (formerly TOPSS) to establish whether his current qualifications satisfy the criteria for the attaining the Registered Manager’s Award. The outcome of this recommendation was not established at the visit. Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23
ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x 3 2 3 Standard No 31 32 33 34 35 36 Score x x 2 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Orchard Close (2&3) Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 22 YES 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 YA 6 Regulation 15 (2)(b) Requirement The registered manager is required to ensure that the changing needs of service users are reflected in their service user plans. The registered manager is required to ensure that risk assessments are in place and reflect current needs. The registered manager is required to ensure that the dignity of service users is respected at all times. It is a requirement that the complaints policy be amended to provide up to date details of the Commission for Social Care Inspection and include information for referring a complaint to the Commission, at any stage should the complainant wish to do so. (This was a previously made requirement). The registered persons are required to recruit staff to ensure a full quota of permanent staff in the home. The registered persons must operate thorough recruitment procedure and ensure that they Timescale for action From 22nd August 2005 & Ongoing From 22nd August 2005 & Ongoing From 22nd August 2005 & Ongoing 21st October 2005 2. YA 9 13 (4) (c) 3. YA 16 12 (4) (a) 4. YA 22 22 (7) (a) 5. YA 33 18 (1) (a) 21st November 2005 28th September 2005
Page 23 6. YA 34 19 Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 7. YA 35 (12) (1) (a) 8. YA 39 9. YA 39 26 10. YA 42 13 (4) (c) hold records of staff that are in line with Regulation 17 (Schedule 2) of the Care Homes Regulations 2001. (This is a previously made requirement). The registered manager is required to ensure that staff work consisitently and collaboratively to meet the the complex and changing needs of service users in the promotion of their health and welfare. Evidence (dated April 2005) provided by the time the report was being finalised, so the requirement to conduct a service user survey has been removed. The registered persons are required to conduct monthly provider monitoring visits on the home and submit reports monthly to the Commission The registered persons are required to promote the health and safety of service users by ensuring that 1) dry food storage is appropriate 2) protocols are in place for the minimisation of risk when using defrosted milk and 3) that fridge/freezer temperatures are recorded and monitored in with health and safety guidance. From 22nd August 2005 & Ongoing From 31st October 2005 & Ongoing From 22nd August & Ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA 37 Good Practice Recommendations The registered manager should liaise with the professional body (Learning Skills Council) to verify whether his qualifications and training would amount to the equivalent of an NVQ level 4 in Management and Care Award.
G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 24 Orchard Close (2&3) Orchard Close (2&3) G55_S0000025913_Orchard Close_V231850_220805_Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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