Inspection on 06/12/05 for Orchard Court

This inspection was carried out on 6th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Orchard Court 23/10/07

Orchard Court 10/07/06

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 Ms S McBriarty Announced Inspection 6th December 2005 11:00 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.V271938.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Orchard Court Address Orchard Court East Grinstead Road Lingfield Surrey RH7 6ET 01342 834444 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) Anchor Trust Maureen Burns Care Home 63 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (15) Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Up to 8 of the beds may be used for SI(E) Up to 10 of the above beds may be used for MD(E) Date of last inspection 19th July 2005 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 and/or a physical disability. The Homes bedroom and community living areas are arranged into seven group living residential units. They are 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 new patio area nearing completion. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the second inspection for 2005-2006. Two Regulation Inspectors carried out the inspection on the 6th December 2005. A pre-inspection report had been completed by the home providing information on for example staffing levels, complaints, policies and procedures and copies of menus. During the inspection a tour of the home took place and a number of staff and residents were spoken with. A number of documents were also sampled including care plans, personnel files, health and safety information and training records. Seventeen comment cards were received from residents, one from relatives and eight from health and social care professionals who have contact with the home and these comments are reflected in this report. The CSCI wish to thank the staff and residents for their welcome and assistance during the announced inspection. What the service does well: What has improved since the last inspection? What they could do better: The home was going through a period of change and members of staff were working hard to achieve the standards laid out in The national Minimum Standards for Older People. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 6 A number of requirements were made including a recommendation to update the residents individual risk assessments. These were in place but required documented review. Considerable work had been achieved regarding activities including an activities folder for all the units except one. A recommendation was made that the remaining unit receive the same documented attention. Two carpets were found to need replacement and a requirement was made to ensure that this occurs. The full list of requirements can be found at the end of this report. 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 Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Work was in progress to ensure that prospective residents can be provided with the information they require to help them make a decision about moving into the home. EVIDENCE: Recent staff changes including a new manager are being included in the updated statement of purpose. A requirement was made that once the statement of purpose had been completed a copy is to be forwarded to the CSCI. The requirement made during the inspection on the 19th July 2005 had been met; the home had revised the pre-admission assessment process to ensure that prospective residents received a comprehensive assessment of their needs. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,11 Care plans were in place enabling members of staff to meet the residents assessed needs. Further work was required to ensure that risk assessments were up to date. Resident’s files contained information regarding their preferred options following their death or should they become ill. EVIDENCE: A number of resident files were sampled, the care plans had been signed by the specified residents. Those files sampled also included information regarding the preferred options of the resident following their death or should they become ill. A requirement was made that each of the resident files be provided with a recent photograph. Comment cards from health and social care professionals who have contact with the home indicate that the home works in partnership and that they are happy with the overall care provided. However two comments from health and social care professional’s state that the home needs to sometimes communicate information more clearly. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 10 Risk assessments were in place, however it is strongly recommended that the risk assessments be updated in order to ensure that appropriate staff support might continue to be provided. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Considerable work had taken place within the home to ensure that the residents might take part in activities that are suitable for them and chosen by them. Further work was required to ensure that all residents were offered the same opportunities. EVIDENCE: The home had employed an activities co-ordinator who had implemented a new system for recording those activities chosen and attended by the residents. An activity file had been put into operation for each of the units in the home. The activities co-ordinator ensured that resident care plans were signed to confirm attendance of otherwise of the specified residents. One unit had not yet been included in the revised system and a recommendation was made to ensure that the specified unit received the same integrated service. The pre-inspection report provided to the CSCI contained a copy of the various activities provided by the home during the course of a week. The revised system met the requirement made during the inspection of the 19th July 2005. Residents and relatives meetings were being advertised around the home, the meetings will be the first held by the home. The manager stated that the Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 12 meetings will offer opportunities for residents and their relatives to discuss their views and express preferences. Comment cards received from residents confirm that that they feel that the home provides suitable activities. Two comments were received that residents would like to be more involved in the decision making process in the home. One individual spoken to said “There is an opportunity to play games in the evening and the staff join in”. Another resident spoken to has a keen interest in art and his paintings were seen on display in the day centre and in his bedroom. At the time of the inspection the home was preparing a Christmas meal to be held in the evening for residents and their relatives and friends. The manager confirmed that suppertime snacks and whether they were taken were now being recorded. This action met the requirement made at the inspection of 2nd September 2004 and the 19th July 2005. The pre-inspection reported provided a copy of the home menu for a period of two weeks and reflected a varied diet. On the day of the inspection the residents had tasted a variety of home made mince pies in order to assist in choosing which they might prefer for the party later in the day. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 13 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): 16,18 The home maintains appropriate records regarding complaints. EVIDENCE: The complaints record was sampled and three complaints were found to have been made. The records evidenced that an appropriate response had been made to each of the complainants. Comments received from residents all indicate, except one that they like living in the home feel well cared for and are treated well. Comments from relatives and health professionals state they are able to visit in private. Two residents spoken stated “ It’s a good place here” and “ The home is very good, the staff are kind and caring”. The pre-inspection report documented that no referrals had been required by the home regarding the protection of vulnerable adults and no member of staff had been referred for inclusion on the protection of vulnerable adults list. Members of staff working in care homes might be referred to the protection of vulnerable adults list if they are found to be mistreating vulnerable adults. The pre-inspection report also noted that the home had a policy and procedure for the protection of vulnerable adults, the policy was not sampled on the day of the inspection. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 14 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): 19,26 A tour of the home took place and confirmed that the requirements made during the inspection of the 19th July 2005 had been met and residents’ safety had been improved. Further work was required to ensure that the home might fully meet the standard. EVIDENCE: New carpets and flooring had been provided in those areas requiring replacement. During the inspection of the 6th December 2005 one specified bedroom was found to require replacement flooring due to the pervading odour and one sitting area carpet also required replacement. A requirement was made for the carpets to be replaced. The bedrooms were seen to clean and had been personalised by the residents. Those residents spoken with informed the CSCI that it was ‘ a wonderful home’ and ‘it’s a good place here’. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 15 A requirement was made during the inspection on the 19th July 2005, that the fencing is secure and in a good state of repair; the fencing was being repaired on the 9th December 2005. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 16 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): 27,28,30 The pre-inspection report informed the CSCI of the staffing levels on duty each day at the home. Qualifying training targets had been met and the home was working toward completing an overall training plan for the staff working at the home. EVIDENCE: The pre-inspection report documented the assessed levels of need of the residents and the number of hours care and support provided by the home to meet those needs. 56 of the members of staff were qualified to National Vocational Level (NVQ) 2 and meeting the minimum target set by Standard 28 of The National Minimum Standards for Older People. The new manager and deputy manager were in the process of identifying the training that had been provided to each member of staff. The home was seeking to ensure that all staff had received the required mandatory training. A requirement was made that the home provide the CSCI with written conformation of the outcome and their plan to ensure all members of staff complete the required training should it be necessary. A number of personnel files were sampled in general the files met the target, one or two were missing either a job description or evidence of identity. It was clear that this was not the homes normal practice and the manager was reviewing the files to ensure that each met the standard. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 17 The home kept a central record of staff names and Criminal Record Bureau (CRB) disclosure numbers, a requirement was made that the home refer to the CRB guidance to ensure that the date of issue is also recorded. The original documents were held by the homes head office and the manager and area manager could not confirm if the organisation kept the records with the CRB guidelines in mind. A requirement was made that the organisation confirms that CRB guidelines are followed regarding storage, recording and disposal of CRB checks. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,38 The home was working hard to achieve all the standards assessed and plans were in place to assist with this matter. EVIDENCE: The new manager had been in post from the beginning of October 2005 and had been reviewing the services provided to residents as well as the support and training provided to members of staff. The manager was completing the qualifying training required to enable satisfactory application for the post of registered manager. The manager had requested an application form for the post of registered manager. It was not possible to confirm whether a previous quality assurance audit had taken place at the home, a requirement was made that the home provide the CSCI with a plan of how it intends to achieve a quality assurance audit of the home during 2006.This will enable the manager and staff to gain a view of how Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 19 the residents, their relatives and professionals feel about the services provided by the home and what action if any is required to improve the service. The home employers liability insurance was up to date and available for inspection. There is a five-year business plan in place. Residents’ personal finances were sampled in order to ensure that the home was keeping clear and accurate records of income and expenditure. It was found that the home keeps only small amounts of money on behalf of the residents meeting the home’s own policies and procedures. Staff supervision on an individual basis had not been taking place. The new manager had been meeting with the senior staff team and using team meetings to discuss matters affecting the staff and home. The manager reported that this was to assist with the management of change within the home and to ensure that time was available for keeping the staff team as a whole informed. Individual supervision was planned to begin in January 2006 a requirement was made that the home confirm in writing to the CSCI that supervision dates had been agreed with staff beginning in January 2006. Those records sampled during the inspection of the 9th December 2005 were generally found to be up to date. As noted previously the risk assessments and supervision provision require work to ensure they are up to date and documented appropriately. The pre-inspection questionnaire had been completed by the home that stated that all the necessary health and safety checks had been carried out within expected timescales. On the day of the inspection a number of samples were taken that confirmed the information provided regarding those checks for example accident records, Legionella testing and water temperatures. The manager reported that the home was in the process of implementing a revised health and safety auditing procedure. The procedure will include checks regarding call points, maintenance equipment and hazards. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 20 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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 2 X 3 Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 21 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. 1. Standard OP1 Regulation 4 Requirement The registered person must ensure that a copy of the revised statement of purpose is forwarded to the CSCI on completion. The registered person must ensure that all necessary risk assessments are updated and documented. The registered person must ensure that a recent photograph of each service user is available in their file. The registered person must ensure that the specified carpets are replaced. The registered person must confirm in writing to the CSCI that the organisation is meeting the guidelines laid down by the Criminal Record Bureau regarding the recording, storage and disposal of CRB documents. The registered person must confirm in writing to the CSCI the outcome of the training review and an action plan, where required stating how they intend to meet the training needs of the DS0000013740.V271938.R01.S.doc Timescale for action 15/01/06 2. OP7 13(4) 15/01/06 3. OP7 17(2) Sch3 23(2)(d) 19(4)(9) (10)(11) 15/01/06 4. 5. OP26 OP29 24/01/06 15/01/06 6. OP30 18(1) 15/01/06 Orchard Court Version 5.0 Page 22 7. OP36 18(2) staff. The registered person must provide the CSCI in writing confirmation of the start date of individual supervision for members of staff working at the home. 15/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP 7 OP12 Good Practice Recommendations It is strongly recommended that the risk assessments for residents be updated. The activities coordinator should consider implementing an activities information folder for one unit that is outstanding. Orchard Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Court DS0000013740.V271938.R01.S.doc Version 5.0 Page 24 - 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. 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