Inspection on 23/10/07 for Orchard Court

This inspection was carried out on 23rd October 2007.

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

Orchard Court 10/07/06

Orchard Court 06/12/05

Orchard Court 19/07/05

Orchard Court 02/09/04

Orchard Court 19/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Orchard Court Orchard Court East Grinstead Road Lingfield Surrey RH7 6ET Lead Inspector Chris Woolf Unannounced Inspection 23rd October 2007 09:10 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 Court DS0000013740.V346546.R01.S.doc Version 5.2 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 Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Court Address Orchard Court East Grinstead Road Lingfield Surrey RH7 6ET 01342 834444 01342 835722 edith.mpatila@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust 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) Miss Michelle Justine Corri Nathan Care Home 63 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (28), Physical disability over 65 years of age (15) Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2006 Brief Description of the Service: Orchard Court is an Anchor Trust Care Home. It is situated in the village of Lingfield and is close to the local shops and community amenities. The Home is purpose built to accommodate and care for up to 63 older people some of whom may have a past or present mental health need, dementia, and/or a physical disability. The Homes bedroom and community living areas are arranged into seven group living residential units. Accommodation is on two floors accessible by passenger lift. There is a Day Centre located at Orchard Court available to residents. The grounds comprise of lawns and a patio area. The current fees for the service at the time of the visit range from £457.00 to £662.00 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is michelle.nathan@anchor.org.uk. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information for this inspection has been gained from a Annual Quality Assurance Assessment (AQAA) completed by the manager; comment cards received from 1 resident, 1 staff member, 5 family members and a care manager; and a site visit to the service lasting 8 hours. The site visit was unannounced which means that neither the residents nor the staff knew that we were going to visit. During the site visit we talked to the majority of residents, 4 in some depth and the rest in passing. We also talked to people who were visiting the home, staff on duty, and to the manager and her deputy. We had a tour of the building and observed the interactions between staff and residents; activities taking place; and lunch being served. A variety of records were examined including care plans, staff files, activities records, quality assurance records, and some health and safety records. What the service does well: This is a friendly and welcoming home, which is led by a competent and positive manager. Comment cards included, ‘First class service’, and ‘They create a happy and liveable atmosphere for residents’, Care plans are comprehensive, regularly reviewed, and reflect all of the residents needs. A caring staff team meets the residents’ needs. Residents commented, “The staff are very good, they have the patience of Job”, and “They are looking after me well”. A good variety of activities, entertainment and outings are arranged for the residents. A staff member commented, “They get plenty of choice of activities”. The food in the home is well cooked, balanced, and gives plenty of choice. A resident said, “The food is very good, good variety and nicely cooked”. Visitors are always made welcome in the home. A visitor said, “They always make me welcome. I don’t have any worries with Nan being here”. The home has good quality monitoring systems in place. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be confident that their needs will be assessed prior to admission to the home and that these assessed needs will be met. EVIDENCE: The manager or her deputy, who may be accompanied by a team leader or member of care staff, assess the needs of all prospective residents prior to admission to the service. These assessments can either take place in the persons own home, in hospital, or if they prefer at Orchard Court. Assessments take into account the prospective resident’s physical and Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 9 psychological needs, health and personal care needs, and also include sexuality, beliefs, choices and specialist needs. Where prospective residents come under the care management scheme a copy of the County Council joint assessment will also be obtained. Assessments give the home the opportunity to assess if they can meet the prospective resident’s needs. The home will only arrange for the admission of a new resident if they are confident that they can meet the prospective resident’s assessed needs. This home does not offer the facility of intermediate care, which is a specialised service designed to maximise a person’s independence (usually on discharge from hospital) prior to them returning to their own home. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are recorded in their plan of care and are met by the staff supported by a multi disciplinary health care team. Residents’ privacy and dignity is respected. EVIDENCE: The home draws up a comprehensive and holistic care plan for each resident based on the information obtained during the pre-admission assessment. Care plans include a variety of assessments, information on the physical and mental health needs of the resident, risk assessments, and any equality and diversity Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 11 needs. Since the last inspection the format of the care plans has changed and all have been rewritten. Each care plan is reviewed and updated on a monthly basis. The homes AQAA indicates that there have been some difficulties in allocations of Care Managers and therefore annual reviews have not always taken place when required. However to alleviate this problem the home has introduced 6 monthly reviews with the residents and families (if the resident invites them), to ensure that they are meeting the residents needs and to action any concerns, these are documented in the residents care plans. The residents’ health care needs are supported and met by the home and a variety of health care professionals including Doctors, Chiropodist, Optician, Dentist, and Aroma therapist. Visitors commented, “They told me when she was not well”, and “They phone me if there are any problems”. One visitor comment card indicated that there had been problems with the care received by her relative but when spoken to she confirmed that things had improved and that she was now very happy with the care he was receiving. Residents commented, “They look after us well”, “They try to do the best for you”, and “I have my flu jab here”. The homes AQAA indicates that the home has introduced the sending of get well cards to residents admitted to hospital - this idea was suggested by a resident at a monthly meeting. Any suspected pressure areas are referred to the District Nursing staff who visit on a daily basis to treat, advise, and provide appropriate equipment. Nutritional screening is undertaken on admission and weights are recorded monthly. Earlier in the year the home had a Falls Awareness Day followed by a quiz and chair based exercises, they also organise a weekly ‘armchair exercises’ session. The homes policies and procedures for the recording, administration, and storage of medication protect the residents. The home does not keep any homely remedies but, when residents have requested these in the past, the doctor was consulted prior to administration. All staff that administer medication have had training in this subject. A care manager comment card included, “I have one service user whose medication has been selfadministered. The home has tried hard to facilitate this”. Residents are treated with respect and the staff in the home uphold their right to privacy. Staff knock on doors before entering. Residents can have their own telephone line if they wish, and there is also a cordless telephone available to enable calls to be transferred to them in their own rooms. A visitor commented “They brought the phone up here for her when I rang”. Comment cards confirmed that the care service either always or usually respects individuals’ privacy and dignity. Comments included, ‘People are very polite at all times’, and ‘If you want anything you ask and they are very helpful’. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead a life that meets their expectations and needs. They are encouraged to maintain contact with family and friends; have choices in all aspects of their daily lives; and receive good food and a balanced diet. EVIDENCE: The home has a full time activities co-ordinator and during the past year her role has been further developed. There is a day centre facility in the home and residents are able to join the day centre clients whenever they wish. Activities also take place in the individual units and the coordinator visits all of the units as part of her normal routine. Activities on offer vary from painting to Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 13 reminiscence; quizzes to bingo; and cake making to manicures. In addition residents are encouraged to take part in activities of daily life such as laying tables, and preparation of fruit salad. The flowers displayed in the home are picked and arranged by residents’. Some residents have grown vegatables and plants in mini green houses, and plants were used for the hanging baskets outside the front entrance. Visiting entertainers are a regular feature in the home. There is a 10-seater bus available and trips out include a weekly bus ride, cup of tea and bird feeding, and trips to places like Eastbourne for Fish and Chips on the pier and ice cream at Beachy Head. A variety of special events are celebrated at the Home including birthdays, Easter Egg Painting and unit decorating competition, Chocolate Fondue afternoon, BBQ and raffle, Mothers Day, and Fathers Day tea and cake afternoon, and Halloween with a pumpkin competition between the units. All activities are recorded in the homes activity record and in individual care plans. A quarterly newsletter has been introduced and, as well as giving information about events, this includes a quiz and a true story from a resident’s youth. The home has also introduced a shop trolley that visits each unit twice a week. Details of planned activities and events are displayed in the units, in the hallway, and in the lift. Residents commented, “I don’t join in activities but I like watching”, “I join in the activities I like, we have concerts and play bingo”, “I play patience, it keeps my mind alive”, and “I am enjoying making Christmas cards”. Visitors said, “They do nice sociable things, they are having a competition as to who can do the best pumpkin”, “she has her hair done”, and “she loved the aromatherapy”. Residents’ religious and cultural needs are supported by the home. Holy Communion is held once a month and the residents who wish can either attend the group service or the priest will visit them in their own rooms. One resident said, “They have holy communion once a month and a lady from the church visits me in between, my religion is important to me”. Currently there are no residents with other faith or cultural needs but the home is committed to support any such needs as they occur. Visitors are made welcome at the home and can visit at any time that is convenient to the resident. A visitor commented, “The staff support me and make me welcome”. Visitors are welcome to join the residents for meal times at minimal cost. Residents are offered choices in all aspects of their daily lives. Residents commented, “There’s no compulsion, you don’t have to get up, they bring you a cup of tea at 7:00”, “We have plenty of choice”, “I make my own bed, I like to do it whilst I still can, it keeps me independent”, and “I can do what I want”. Residents can bring their own personal possessions with them to the home. Residents said, “I have got my own sheets”, and “This is my own furniture”. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 14 Residents receive a wholesome, nutritious and balanced diet. Comments from residents included, “The food is very good. The cook has been here for 28 years and is very obliging. I cant have fried fish but they always give me something else”, “They give us fruit”, “The food is very good, good variety and nicely cooked”, and “The food is excellent, 15/10, the cook is top class”. A visitor said, “The food is very good, not at all school mealsy, its much better than I used to get at school”. Food is served to the individual units in heated trolleys. Menus are displayed in each unit. Residents always have a choice, and this is given at the time of the meal, although residents can request further alternatives in advance. Special diets and cultural foods are catered for as necessary. Where pureed food is required this is attractively served. All of the food is freshly home cooked and the cook has also started to make speciality breads. The cook visits each of the units at lunchtime to gain feedback from the residents and a feedback book is also kept. Extracts from the feedback book included, ‘To xxx and all kitchen staff, just a thought in appreciation of all you do for me, thank you’, and ‘xxx said his toad in the hole was 15/10’. A member of staff commented, “She is a wonderful cook”. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents concerns and complaints are listened to and acted upon, and they are protected from abuse EVIDENCE: The home has a clear and accessible complaints procedure a copy of which is available in the statement of purpose and service user guide; it is also on display in the hallway. The home’s AQAA indicates that there have been 11 complaints during the last 12 months and that all were resolved within 28 days. No complaints have been raised with CSCI. A resident said, “I’ve never needed to complain”, and a visitor comment card included ‘First class service’, and ‘There is no fault, very nice helpful staff’. One visitor comment card indicated that the person had complained in the past but that the manager had dealt with the complaint and resolved it satisfactorily. The manager encourages residents and their representatives to discuss any concerns they may have with her at an early stage. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 16 The AQAA also indicates that there have been 2 safeguarding adults referrals and investigations in the last 12 months. These have both been successfully completed. It has not been necessary for the home to make any referrals to the Protection of Vulnerable Adults list. Anchor homes have appointed a specific person (Care Specialist) to support a consistent approach to Adult Protection, and ensure processes are in place to monitor and feedback to them and lessons learnt. All staff are trained in Protection of Vulnerable Adults and they have an annual recap on the training. All new staff are checked against the Protection of Vulnerable Adults register prior to employment. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is clean, comfortable and homely with bedrooms personalised to meet their needs. Residents are protected by the homes infection control procedures. EVIDENCE: This is a purpose built home with accommodation arranged in 7 separate units, all with their own lounge dining and kitchenette areas. Furniture and fittings in the communal areas is homely and new dining room furniture has been Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 18 provided for each of the units and the day centre in the past year. A resident said, “Its nice and cosy here”, and visitors commented, “It’s a nice place”, and “Its homely, they have got a cat here and a fish tank”. The home has a planned programme of routine maintenance and renewal and on the day of the site visit carpets were being laid on the first floor landing. A visitor commented, “They are just redoing all of the carpets and curtains”. In addition to the communal areas on the units, there is also a large lounge for residents on the ground floor and sitting areas in the hallways at both ground and first floor level. The outside area is well maintained and provides a variety of sitting areas for residents and space for them to wander in the fresh air. Residents’ bedrooms are personalised to meet individual needs and they are able to bring some of their own furniture and ‘odds and ends’ to make their rooms homely. Residents’ comments included, “This room is my home”, and “I like my room, I have a nice comfortable bed”. A visitor commented, “The only downside is that she has not got an en-suite, but the toilet is right opposite”. The home is clean and free from unpleasant odours. A visitor commented, “Its always nice and clean”, and a staff member said, “The housekeepers do a good job”. During the past year the number of housekeeping hours has been increased. There are robust policies and procedures for the control of infection. Hand washing facilities are prominently sited and alcohol gel hand cleaner is also available. There is one main and 2 smaller laundry areas, all are clean and well maintained and have the appropriate facilities to deal with soiled laundry. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A team of properly recruited and well-trained staff care for the residents. EVIDENCE: There have been a number of staff changes in the past few months. A new deputy manager has been appointed and there are 3 fairly new team leaders. The home has also started to employ bank staff to cover peak times. Although currently the housekeepers work in more that one unit is the aim of the home to have a housekeeper on each unit. As the dependency of the residents has dropped recently there is currently sufficient staff on duty to meet the needs of the residents. However comments from visitors and staff indicate that this is not always the case and a recommendation is made that staffing levels and residents’ dependency are kept under continual review and that staff levels are increased if dependency increases. The home encourages staff to undertake NVQ training and the AQAA indicates that 60 of staff have either qualified or are working towards their NVQ. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 20 The home has robust recruitment procedures. No new member of staff is employed until 2 satisfactory references and an Enhanced Disclosure from the Criminal Records Bureau have been received. The homes employment application form has been updated and now requests a full employment history. The home employs a variety of staff of differing ages and ethnic backgrounds. Staff recruitment includes a ‘selection day’ when the prospective staff members visit the home. During the course of this day, not only does an interview take place but also a resident gives the person a tour of the building and talks to them. The resident’s comments are then taken into consideration when making a decision. Anchor Homes has obtained the Investors in People accreditation for recognising the value of their staff. All new staff undertake B.Tec induction training. In addition to keeping mandatory training up to date, during the past year staff have received training in Dying with Dignity, Continence and Catheter Care, Diabetes, Nutritional Screening, Dementia, and Deaf awareness. All staff that administer medication have received training and team leaders are doing an additional course on ordering and checking of medication. Team leaders have received training in supervision and mentoring, and the Activities Coordinator has had training in Creativity for Dementia. The cook has obtained her Intermediate Food Hygiene certificate and has qualified to teach Basic Food Hygiene. She also organises courses in Dining with Dignity. Orchard Court is the first Anchor home in the country where the Deputy cook has passed ‘Cater Craft’, a course that also involved her attending the local college. Staff from the home staff took part in the Lingfield 6 mile marathon and fun run and raised £300 for the residents welfare fund. Residents comments about staff included, “The staff are very helpful”, and “They are all nice”. Visitors said, “The staff are very nice”, “They are very pleasant, everyone smiles”, and “They are very good”. Staff comments included, “I am very happy”, “It’s never boring here”, and “I’ve worked here a long time so it must be O.K.”. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from positive management and a home that is run in their best interests. The health, safety and wellbeing of residents and staff is promoted EVIDENCE: The Registered Manager is qualified and competent to run the home. She and her deputy have an on going training programme which includes Dementia, Managing Investigations and Health and Safety. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 22 Residents and staff benefit from the positive management approach to the home. Staff spoken to confirmed that they get support from the manager. Residents said, “There are no problems with the managers”, “Michelle is very good, and her deputy” and “Its very good here”. A visitor said, “Michelle has brought in some new stuff and a good attitude”. The home has developed a comprehensive quality assurance system. The company holds the Investors in People Accreditation and the manager has received Investors in People training, and is an internal IIP reviewer. Quality questionnaires are circulated to service users twice a year. Visitors and visiting professionals are also asked to complete questionnaires, and an analysis is produced of all the results. In addition to regular Regulation 26 visits audits include Finances, Service user plans, Medication, and Health & Safety safe site audit. The company have a Self Assessment manual, and this is currently being updated. A Quality assurance report is e-mailed to the Care specialist monthly. Regular meetings include monthly residents meetings, monthly team leader and unit meetings and 2 monthly staff meetings. Comments from residents on the homes quality assurance include, ‘Pleased with what they do for us’, ‘I could not get better service at The Ritz’, and ‘The housekeepers do a first class job, and everywhere is spotlessly clean’. Visitor comments included ‘Everyone seems most friendly and welcoming’, and ‘Everyone is very friendly at Orchard Court. The level of care is very good’. Residents or their representatives look after their own financial affairs. However the home do look after some petty cash for residents when requested. All monies are stored securely and access is limited to the Registered Manager and the administrator. The home has a good system in place for the recording of all transactions. The home has clear Health & Safety policies and procedures. All staff are trained in the mandatory Health and Safety related subjects. All accidents are properly recorded. Safety checks on all equipment is up to date. The home has one ‘back care coordinator’ and a further 2 staff will complete this training shortly. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard OP27 Good Practice Recommendations Staffing levels should be kept under continual review and increased when resident dependency increases. Orchard Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Court DS0000013740.V346546.R01.S.doc Version 5.2 Page 26 - 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. 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