Inspection on 25/08/09 for Orchard Court Care Home

This inspection was carried out on 25th August 2009.

CQC found this care home to be providing an Adequate service.

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 Care Home 26/08/08

Orchard Court Care Home 03/09/07

Orchard Court Care Home 18/08/06

Orchard Court Care Home 18/01/06

Orchard Court Care Home 29/09/05

Orchard Court Care Home 17/03/05

Orchard Court Care Home 18/05/04

Orchard Court Care Home 19/01/04

Orchard Court Care Home 14/07/03

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Larchfield Manor

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Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Orchard Court Care Home 7 Wrawby Road Brigg North Lincolnshire DN20 8DL Lead Inspector Kate Emmerson Key Unannounced Inspection 25th August 2009 09:45 DS0000002869.V377341.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Court Care Home Address 7 Wrawby Road Brigg North Lincolnshire DN20 8DL 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) 01652 653845 Orchard Court Residential Home Ltd Manager post vacant Care Home 26 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling in any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 26 26th August 2008 Date of last inspection Brief Description of the Service: Orchard Court is close to the centre of Brigg, and all the local amenities Bedrooms are provided over two floors, and there is chair lift access to the first floor There is parking to the front of the building. The current scale of charges for services provided through the home are between £355 and £455 per week. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star adequate service. This means that the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last key inspection of the home and includes information gathered during an unannounced site visit to the home. An Annual Quality Assurance Assessment (AQAA) had been returned to the Commission by the management of the home. Surveys were sent out to people who lived in the home and staff. People who lived in the home returned five of ten surveys sent out and five of ten sent for staff were returned. During the site visit the inspector spoke to the manager, the services Operations Director and four members of staff. The inspector also spoke with people living in the home. This included talking to people individually and in small groups. We examined a random selection of records and we completed a tour of some of the bedrooms and communal areas. Additional information received by the Commission since the last inspection has been used to inform some of the evidence provided in this report. What the service does well: New people that are admitted to the home had had their needs assessed to see if they could be cared for in the home. The home recorded, in detail, how people would like their needs to be met and their preferred routines. Observation indicated that people’s individual needs were attended to as per the care plan and that staff promoted people’s privacy and dignity. The health care needs of the people living in the home were well met. Staff were provided with the right training to make sure that they understood Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 6 peoples needs and to make sure that they could do their jobs well. People were enabled to take control of their medication. The home was clean, tidy and comfortable and there was ongoing redecoration of the home. People were consulted about the quality of the care they received and felt they could say if they were unhappy about anything. Meals were well balanced, home cooked and enjoyed by people living in the home. The people that lived in the home said that they were well looked after and they are happy to be living there. What has improved since the last inspection? What they could do better: The management must ensure that staff follow the homes medication procedures in terms of maintaining records and completing risk assessments for people who wish to self medicate. This is necessary to reduce the risk of errors and ensure the health, safety and welfare of people living in the home. The activities programme should be maintained in the coordinators absence to ensure that people have the opportunity for social stimulation. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 7 Staff need to be provided with the more frequent supervision to make sue that they understand how people need to be looked after, and to see if they need any other training to help them to do their jobs. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 9 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 Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had their needs assessed prior to admission so that they could be confident the home could provide the care they required. EVIDENCE: The home made sure that people’s needs could be met within the homes registration by assessing their needs prior to admission. Where Social Services care management teams funded people’s care, the home had obtained copies of their assessment and care plan. The home had developed a detailed assessment format. Four care files were examined of those most recently admitted to the home and the assessments Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 11 were very detailed. They included information regarding people’s health needs and social interests and relevant risk assessments. The information gathered at assessment had been developed into detailed care plans, which described how needs, should be met and risks minimised. The care needs of people living in the home were discussed with the staff on duty and they were able to explain the specific care requirements related to them. To help people feel settled on admission the home provided information about the service and the facilities, welcome cards and baskets of toiletries in bedrooms. One person said they choose the home for their relative because it felt homely. Intermediate care is not provided at the home. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care needs of people living in the home were met through the services provided in the home. Medication policies and procedures were not always followed by the staff and this increases the risk of errors and medication not being administered as prescribed. Additional procedures were immediately implemented by the management to improve this area. EVIDENCE: We looked at the care files for four people who lived in the home. The care plans identified the needs that had been highlighted in the individual’s assessments and these had been evaluated on a regular basis to make sure that they were still appropriate. Two of the care plans had not been evaluated Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 13 for two months prior to inspection. Care must be taken to ensure that plans are evaluated at least monthly to ensure that they are kept up to date. The care plans were very detailed. They identified how people’s health and personal care needs were to be met. They also included likes and dislikes and detailed personal routines. Records described the care delivered and communication with health professionals. These identified that staff were able to met people’s needs in a timely manner and could identify when referral was required to other agencies. Where health professionals had given instructions regarding care provision these were detailed in care plans. People living in the home or their representatives had seen and agreed to their care plans. Whilst all the care required was detailed in care plans they would benefit from more specific instructions for catheter care, infection control issues and management of challenging behaviour. One person displaying regular episodes of challenging behaviour had been appropriately referred to a specialist health professional. It was recommended that separate records of each episode of challenging behaviour were maintained to help inform the specialist assessment. The home used monitoring records to record, for example, when pressure relief had been provided and dietary intake. These had been completed on a consistent basis and were audited regularly by a senior member of staff. Where one person was turned regularly the records showed the person had been put on the same side a number of times in succession. The manager explained that the person had some movement which may account for the discrepancy but this had not been followed up and investigated by the person auditing the records. This is recommended if the process of auditing is to be effective. The staff interviewed had an understanding of people’s needs and how they should be met. The home had detailed medication policies and procedures to support safe practice. The acting manager stated that only senior care staff administer medication. The staff administering medication had stated that they had received accredited medication training and the homes training records supported this. They had also had refresher training and systems training. Administration of medication was observed and staff were seen to support people appropriately and supervise them until they had taken their medication. Medication records included a photo of people and their preferences in taking their medication. One person spoken with was observed to be independent with their medications. However a risk assessment had not been completed to ensure that this was safe practice even though this was part of the homes written Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 14 procedures and a format for recording the assessment had been given to the acting manager for completion. The area manger had identified recording errors as part of a medication audit and had reported these to the Commission prior to the inspection. She had provided an action plan to indicate that audits would be completed fortnightly. At the inspection there was no evidence that these had been completed. Checks on the records at the inspection showed that appropriate entries had not always been made in the controlled drug register. This evidenced that staff were not always checking the balance of medication prior to administering the next dose and they had not reported omissions in the records to the manager. Records and checks on balances of medication evidenced that one person had not received their controlled medication for pain relief as prescribed on one occasion. The area manager immediately put processes in place to investigate the issues and referred the error to the safeguarding team. Additional procedures were put in place immediately following the inspection including a daily controlled drug record and stock audits. People felt they were well cared for and that their privacy and dignity was protected. Comments included ‘I am well looked after if I need help’, I am very well cared for, they are super, we are all treated with respect’ and ‘the staff are all lovely you can talk to them and it makes you feel better’. Care plans included specific details relating to people’s appearance, dress, jewellery and perfume and individuals ability to maintain their own privacy and dignity. Observation identified that these care plans were adhered to. People’s rooms were personalised to their own tastes and they were able to bring in some of their own possessions. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All the above standards. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have choice in their daily lives and usually enjoy varied activities and good quality meals. EVIDENCE: People’s social, personal and religious needs were identified as part of the assessment process. If people wished to follow their religion whist at the home then this was also identified. The homes activity coordinator, who normally works twelve hours per week, was temporarily unavailable to work at the home. No additional care staff hours had been provided during this time and staff confirmed that they had now had responsibility to provide activities. Staff stated however that they do not always have time to do activities due to the demands of other work. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 16 Records showed that a wide variety of activities had been provided up to the activity coordinators absence. People who lived in the home stated that there were usually activities that they could participate in. One person said they would like to go out more. There was evidence from discussions with people who lived in the home that confirmed they were able to exercise choice in all areas of their life from times they got up and retired to bed to the meals provided. People’s preferences for care delivery and likes and dislikes were recorded in care files and medication records. The dining room was spacious and comfortable. The care staff were observed to assist people with meals individually and where required in a way that supported their dignity. The information provided to the Commission stated ‘we have an open visiting policy and encourage families and friends to take their relatives and friends out for periods or away on holiday’. One person living in the home said ‘they make my husband feel very welcome’. The home had a 4-week rotating menu that included two choices at lunchtime and teatime. One of the cooks confirmed that menus were reviewed regularly and residents were consulted about the meals at meetings. The cook was knowledgeable about people’s dietary needs and described how these were met. People were also able to comment on the quality of the meals provided through the homes quality assurance monitoring system. People’s comments about the food included ‘the meals are good and there is plenty of choice’, ‘meals are top class, couldn’t get better, they are different every day and there is a very good choice’ and the food is very good, they made me a cake for my birthday with candles’. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were happy living in the home but felt able to complain if required. People living in the home had been protected from abuse. EVIDENCE: The service had a clear complaints policy and procedure and copies of this were seen to be available around the home. Records of complaints were maintained. With the exception of one person who responded in surveys people indicated that they understood how to make a complaint if they wished to. The people living in the home were happy with the care they received and felt they could speak out if they were not happy. One person said ‘staff are all lovely, you can talk to them and it makes you feel better’. The home had policies and procedures to safeguard people and to protect them from abusive situations. Staff training records supported the evidence that they had received training in relation to the protection of vulnerable adults and had received refresher training. Care staff spoken with confirmed that they had received training and their responses also showed that they were aware of how to report any allegations of abuse at the home. One person spoken with said ‘I feel safe here’. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provided a clean, tidy and well maintained home with a homely atmosphere. EVIDENCE: Two new ensuite bedrooms had been created within the home and these had been registered with the Commission The garden area had been mostly paved and a large patio area had been created which was accessible to people living in the home. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 19 We made a tour of the premises and found the home to be clean and tidy and free from any offensive odours. People in surveys stated that the home is usually fresh and clean. One person said that it is ‘clean and tidy and like home from home’. The home was undergoing decoration and refurbishment and a number of bedrooms had been redecorated since the last inspection. A bathroom had been converted in to a walk in shower to ensure a variety of bathing options was available. This required finishing in respect of the electrics which required boxing in. All the requirements and recommendations from the previous inspection had been addressed. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All the above standards People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff were appropriately employed to work at the home and they received training required for their role. Residential forum guidelines were applied to determine staffing levels and people living in the home felt they were well cared for. EVIDENCE: There was evidence that staffing levels in the home were calculated using the Residential Forum Guidelines. This requires the home to monitor the dependency levels of people living in the home and use this information together with the staffing guidelines to determine the number of weekly staff hours required. People who live in the home told us that they received the care and support they needed and the staff were available if they need them. Staff had conflicting views of the staffing levels. Of the five staff who responded to surveys two thought there were always enough staff to meet peoples needs, two thought there was usually enough staff and one said there Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 21 was never enough staff. Comments about staffing levels included ‘it’s a bit hectic at times’, ‘staffing is quite organised’ and ‘ more staff at key times would be useful as it can be very busy, leaving the staff stretched and not always available if someone requires assistance’. People said that they liked the staff, comments included ‘staff are very good’ and staff are very good they are always kind and polite. They come when you ring the bell’. Staff training had been provided since the last inspection. Training records showed that staff had completed the mandatory training that is required of them and some specialist training had been provided in relation to dementia care. A regional training manager has been employed by the company to ensure that the training programme continues to develop and is implemented. There was evidence in staff files that new care staff to the service completed induction training. One new staff member stated that their induction training had included five or six shifts where she was extra to the staff rota so that she could shadow staff and get to know people’s routines. Staff personnel files were checked to make sure that all of the appropriate safety checks had been completed before they were employed to have any contact with people living in the home. Evidence was available that supported that the staff receive two references and a POVA 1st (Protection of Vulnerable Adults) Criminal Records Bureau (CRB) vetting before their employment commenced at the home. The management and staff were committed to National Vocational Training (NVQ). The AQAA stated that eight of the fourteen care staff have completed NVQ qualifications in care. The cooks and domestics were also encouraged to complete NVQ training relevant to their role. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There had been some changes to the management but processes had been well maintained. They consulted with people who lived in the home on a regular basis through quality monitoring. The health and safety of people living in the home was protected. EVIDENCE: The home had been without a manager for eight months until the recruitment of a new manager. The head of care had been acting manager during this Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 23 time. She had maintained the majority of management tasks to a satisfactory level and improved other areas such as care planning. The new manager had been employed at the home for a month prior to the inspection. The manager said she was experienced in this role and had worked as a registered manager in other homes. She stated that she trained as a state enrolled nurse and had completed NVQ 4. The home had a system of monitoring the quality of care in the home. There was evidence that the quality assurance and monitoring system had been improved and used in a more consistent way. Recent surveys that had been sent out to people who lived in the home, these had been evaluated and action plans had been formulated. Outcomes of this process had been published and made readily available to people living in the home and visitors to the home. The interviews with care staff and observation of their personnel files showed that although some formal supervision had been provided, the recommended minimum of six formal supervision periods per year pro-rata had not been achieved since the last inspection. The frequency of supervision should be improved to at least a minimum of six sessions per year so that the staff development and support is maintained. Staff stated that that they felt supported by the management. The home had achieved the Investors in People Award. Where the home assisted people with their finances clear records were maintained and receipts were held for transactions on their behalf. The management provided evidence that all of the equipment that required servicing and maintenance had these carried out on a regular basis. This included the moving and handling equipment. The home also had up to date certificates for the fire, electrical and gas appliances. Staff had received training in mandatory areas such as moving and handling and first aid. The systems for ensuring that people would be protected in the event of a fire had improved and previous requirements were met. The fire alarm had been tested weekly although records did not follow concurrently as different sheets had been used at different times. Detailed records of accidents were maintained. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 24 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 2 X 3 X 3 2 X 3 Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Requirement The medication records must be clearly and accurately maintained to reduce the risk of errors and to ensure people receive medication as prescribed. Timescale for action 01/11/09 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 OP9 Good Practice Recommendations Where people wish to self medicate whilst living in the home a risk assessment should be completed to ensure the health, safety and welfare of the person and others living in the home. The activities programme should be maintained in the coordinators absence to ensure that people have the opportunity for social stimulation. The registered person must make sure that all of the care staff receives the recommended minimum of six formal DS0000002869.V377341.R01.S.doc Version 5.2 Page 26 2 3 OP12 OP36 Orchard Court Care Home recorded supervision periods per year (pro-rata) to ensure that they understand their roles and to identify any training needs that they may have. Orchard Court Care Home DS0000002869.V377341.R01.S.doc Version 5.2 Page 27 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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