Inspection on 26/08/08 for Orchard Court Care Home

This inspection was carried out on 26th August 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orchard Court Care Home 25/08/09

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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Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/11/2008.

CARE HOMES FOR OLDER PEOPLE Orchard Court Care Home 7 Wrawby Road Brigg North Lincolnshire DN20 8DL Lead Inspector Kate Emmerson Key Unannounced Inspection 26th August 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Orchard Court Care Home DS0000002869.V370798.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 Care Home DS0000002869.V370798.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 Julie Margaret Shepperson Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (24) of places Orchard Court Care Home DS0000002869.V370798.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 and Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 24 3rd September 2007 2. 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 £340 and £360 per week. Orchard Court Care Home DS0000002869.V370798.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 1 star. This means that the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) 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 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 nine of ten surveys sent out and one of ten sent for staff was 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 the majority of 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. For example people had been assisted to wear the jewellery they liked as stated in their care plan. 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 peoples needs and to make sure that they could do their jobs well. People were enabled to take control of their medication within their own abilities. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 6 The home was clean, tidy and comfortable although there were some health and safety issues that needed to be addressed. People were consulted about the quality of the care they received and felt they could say if they were unhappy about anything. They had access to varied activities and were able to go out into the community. 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: They must make sure that they address maintenance problems in the home quickly so that the home is safe and looks attractive for people living there. For example they had not made sure that fire doors were working properly and paper was hanging from one the bedroom ceilings. 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. The management of the home need to make sure that there are enough staff working in the home to care for the people that live there. The management need to recognise when safeguarding procedures must be implemented and refer allegations of abuse in a timely manner. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 7 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 Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3, standard six does not apply, as the home does not provide intermediate care. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received the information they needed to make an informed choice about the home and had their needs assessed prior to admission so that they could be confident the home could provide the care they required. EVIDENCE: The statement of purpose and the service users guide were displayed in the hallway so that visitors and people living in the home could access the information easily. In surveys people commented that they had received enough information about the home before they moved in. One person stated that they chosen the home because they ‘knew a previous resident’ another said ‘I had already been staying here for respite, for which I was well satisfied’. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 10 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. Two care files were examined of those most recently admitted to the home and the assessments 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. Intermediate care is not provided at the home. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available 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. EVIDENCE: The home had worked hard to improve the care plans since the last inspection. They had further developed the process and provided care plan training. The care plans had also been quality audited and discussion about care plans was included in staff supervision sessions. 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. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 12 The care plans had been improved and 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, which described the care delivered, and communication with health professionals, 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. The care plans and risk assessments had been regularly evaluated and updated. People living in the home or their representatives had seen and agreed to their care plans. The home used monitoring records to record, for example, when pressure relief had been provided and dietary intake. However these hadn’t always been completed on a consistent basis to be an effective tool. People living at the home were generally very positive in relation to the care that they received at Orchard Court. One person said ‘the staff are lovely, they make you feel very comfortable’ another said ‘I am very happy here and well cared for’. The staff interviewed had an understanding of people’s needs and how they should be met. They said they found the care plans useful and reflective of peoples needs. The 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. One staff member started that she been observed three times to test her competency before being allowed to administer medication unsupervised. Administration of medication was observed and staff were seen to support people appropriately and supervise them until they had taken their medication. One person was supported to be more independent with their medications and this was detailed in risk assessments and the care plan. Medication records included a photo of people and their preferences in taking their medication. Appropriate entries had not always been made in the controlled drug register and evidenced that staff were not always checking the balance of medication prior to administering the next dose or reporting omissions in the records to the manager. The manger had identified the errors but did not keep records of any action taken this is recommended. Other records evidenced that people had received their controlled medication as prescribed and controlled medication checked balanced with the records. The records must be completed fully to minimise the risk of errors. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 13 People felt they were well cared for and that their privacy and dignity was protected. 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. Comments about the care and staff included ‘staff are very good’, ‘staff are lovely’, and ‘I am alright, I am comfortable here’. A relative said ‘the care is excellent’. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have choice in their daily lives and 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 had left the home in June 2008 but the home was advertising to fill the post. Staff confirmed that they had responsibility to provide activities and this was highlighted on the rota. There was an activity plan displayed and records of activities provided and who had taken part were maintained. In surveys and those spoken with stated that the activities in the home were frequent enough and that there were a variety of activities available. People stated that that they are provided with the opportunity to go Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 15 out to the local shops and pubs and further visits to the coast and shopping centres were also available. 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 their care delivery was recorded in care files and medication records. The dining room was spacious and comfortable and the carpet had been replaced since the last inspection. 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’. 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 and a survey had been completed prior to the inspection. People’s comments about the food included ‘the food is very nice’, ‘the food is good’ and ‘ the food is not bad really’. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were happy living in the home but felt able to complain if required. Whilst people living in the home had been protected from abuse there was a lack of management understanding of multi agency safeguarding procedures and when they should be implemented. EVIDENCE: The service had a clear complaints policy and procedure and copies of this were seen to be available around the home. With the exception of two people 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. Comments included ‘if you don’t like anything you can say something and that’s important’, ‘I am very happy here’ and ‘I feel very comfortable’. 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. 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. Complaints records evidenced that staff understood Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 17 their responsibilities in reporting possible abuse. However it is recommended that staff receive annual refresher training in this area and this had not been provided for all staff. The Area Manager wrote to us following the inspection stating that all staff would receive refresher training by the first week in September 2008. It was highlighted in the homes Annual Quality Assurance Assessment that the home had received three complaints. Two of these involved allegations of abuse. One complaint relating to the manager and medication issues had been investigated by the Local Authority safe guarding team and had been partially founded in respect of the medication issue. However in the other case, regarding an allegation of poor care/neglect by night staff, a referral to the safeguarding team had not been made and the home had commenced an internal investigation. The management had protected people in that they had implemented their own disciplinary procedures. The manager was advised to contact the Local Authority immediately to refer the complaint to ensure the correct procedures were followed and this was done before the end of the inspection. On discussion with the local Authority safeguarding team following the inspection they confirmed that they would be undertaking their own investigation. Minor concerns were recorded in order to improve the quality of the service. Staff personnel files that were examined provided evidence that appropriate safety checks were completed by the service prior to the staff being employed to work in the service or have contact with people accommodated. This helped to protect the health and safety of people at the home. Orchard Court Care Home DS0000002869.V370798.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service provided a homely atmosphere but there were some deficiencies, which could put people’s health and safety at risk. EVIDENCE: The home had had major building work taking place in the garden of the home since the last inspection to create nine ground floor homes to accommodate people living independently to the care home. The manager and the area manager were strongly advised that if any services were to be provided to these units from the care home these must be discussed with the Commissions registration team. This to make sure that there is not a breach of the care homes registration and that they do not operate an unregistered service. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 19 As part of the building work two new bedrooms had been created within the home. At the time of the inspection the Commission had not received a request for these to be registered. The rooms are therefore unable to be to be used until registration is complete, the management were aware of this requirement. The garden area had been mostly paved and a large patio area had been created which was accessible to people living in the home. 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 indicated that the home is usually fresh and clean, however a relative said ‘there is often a very strong smell of urine in the corridor leading to my relatives room’. Discussions with the manager and observations during the tour of the building provided evidence that a number of requirements made at the last inspection had been met. This included provision of a new call bell system, provision of a handrail to cellar steps and linen cupboard in the bathroom and taps being replaced. The home was also undergoing decoration and refurbishment and a number of bedrooms had been redecorated since the last inspection. A new carpet had been fitted in the dining room and this area was being redecorated at the time of this inspection. There were a number of issues with the management of fire safety in the home relating to fire doors. In three bedrooms the doors would not close due to door guards catching on carpets on release. In another bedroom the door would not close due to the position of the bed and bedding blocking the door. The fire exit door to the first floor fire escape would not fully open as there was water damage to the door causing it to catch on the fire escape. The handy man was called in to address the issues on the day of the inspection. The issues raised indicated that staff do not ensure fire doors were closed at night and that the doors were not checked as part of the fire alarm system checks. We requested that the manager contact the fire department for advice on a separate matter and we informed the fire officer of our findings in relation to fire doors to the fire officer. The fire officer visited the service and completed full audit of the home. An action plan has been provided to the Commission by the home to inform us how issues raised in the fire officer’s audit will be addressed. Other issues noted during the tour of the building: The handyman completed weekly checks on water temperatures but during the tour of the building the hot water in the ground floor bathroom was recorded Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 20 (on the homes thermometer) at 47°C. The hot water should be maintained close to and not exceeding 43°C to minimise the risk of scalding. Room 6 had paper hanging from the ceiling, which was unsightly and may be an indication of a leak to the roof. Carpets in rooms 19 and 20 were stained. The radiators had been provided with protective covers to make sure that people were not injured through any direct contact with them. However in bedroom 19 the radiator cover was missing. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 21 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 and 30 People who use this service experience adequate outcomes in this area. This judgement has been made using available 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. However Residential forum guidelines were not fully applied to determine staffing levels and the home was working slightly under the recommended levels. Some people thought their needs were not always met due to staffing shortages EVIDENCE: The 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 use this with the staffing guidelines to determine the number of weekly staff hours required. Whilst the home provided evidence that dependency levels were monitored and the staffing tool was used this was still not being correctly applied. The evidence provided by the home showed the staffing levels calculated by the home were still not including the hours required for the difficulties in relation to the general layout of the environment and that one or more people required special assistance. The staffing levels in the home are maintained just below the minimum guidelines for example the staff rotas showed that at the time of Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 22 the inspection the home were providing 393 hours per week but checking the residential forum with dependency levels provided by the manager this should have been 407.19. Staffing in the home was arranged so that there were more staff on duty at busy times of the day. Staff felt that they were able to meet people’s needs with the staffing levels provided. People said that they liked the staff, for example comments included ‘the staff are lovely they make you feel very comfortable’, ‘I am well cared for’ and the ‘staff are very good’. However there were some comments, which indicated that at times, there might not be enough staff on duty. Comments from people living in the home included ‘the girls do their best but at times seem to be under staffed’, ‘staff shortage makes it difficult for staff to be available when you need them, they are often busy with other residents and not available, sometimes no one available to speak to’, I am not taken to the toilet when I ask. I have to wait too long’ Staff training had been provided since the last inspection and training records showed that staff have completed mandatory training that is required of them and some specialist training had been provided in relation to dementia care, infection control. Staff had received training in protecting people from abuse. However it is recommended that staff receive annual refresher training in this area and this had not been provided for all staff. The Area Manager wrote to us following the inspection stating that all staff would receive refresher training by the first week in September 2008. The home’s induction programme includes the national standards for care. 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. The home had also implemented a coaching and mentorship system to support people for moving into more senior roles. 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 Criminal Records Bureau (CRB) vetting before their employment commenced at the home. The management and staff were committed to National Vocational Training (NVQ). Evidence from training records and discussions with the manager and staff identified that approximately 48 of the care staff have completed NVQ qualifications in care and a further six staff are working towards NVQ awards at different levels. The cooks and domestics were also encouraged to complete NVQ training relevant to their role. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 23 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, 33, 35, 36, and 38 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home was approachable and understood the needs of the people. They consulted with people who lived in the home on a regular basis although quality monitoring was not fully implemented in all areas of the home and had led to some deficiencies in the management of health and safety. EVIDENCE: The manager of the service had completed her Registered Managers Award in 2005 and has completed other training relevant to the role such as foundation in Management and BTEC in Care. The manager of the home had successfully Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 24 completed the registration process with the Commission to be the registered manager of the service. The home had a system of monitoring the quality of care in the home. There was some evidence to suggest that the quality assurance and monitoring system had been used in the home since the last inspection. However the quality assurance records were poorly filed and the most recent surveys that had been sent out to people who lived in the home and staff had not been evaluated, action planned or published. The area manager completed this piece of work and provided copies to the Commission. The manager stated that results of surveys were discussed with people at meetings. There were records available to evidence that regular meetings were held at the home for staff and people using the service. Records showed that people were able to air their views on the running and development of the service. Staff and service users spoken with felt that the management would listen if they had anything to say. One service user stated ‘if you don’t like anything you can say something and that’s important’ and a staff member said ‘ the management are very approachable’. 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. Records showed that staff had received three sessions of supervision 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. 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 top date certificates for the fire, electrical and gas appliances. Staff had received training in mandatory areas such as moving and handling and first aid. A fire risk assessment was in place although the home was working against their own assessment by allowing staff to live on the top floor of the home. The manager was requested to liaise with the fire officer on this issue. The fire officer later stated that staff could live on the third floor if fire detection systems were fitted. The systems for ensuring that people would be protected in the event of a fire were not always maintained. The fire alarm had been tested weekly since the beginning of July 2008 but had been less frequent than this in previous months. Some fire doors did not always open/close. Some immediate work was undertaken by the home on the day of the inspection to ensure that fire doors did operate fully. These issues were also referred to the fire officer and a full audit was undertaken. An action plan was provided to the Commission to Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 25 show how the home would meet the fire officer’s requirements. These issues showed that systems had not been effectively monitored and that staff did not feed back any problems or they did not fully understand what constituted a risk. Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 26 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 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) 17(1) Requirement The registered person must make sure that the controlled drug register is always used to record administration of controlled medication. This is to minimise the risk of errors. The registered person must make sure that safe guarding procedures are followed when an allegation of abuse has been received in order that appropriate investigations are completed and people are protected. The registered person must make sure that fire doors are fully operational to protect people in the event of a fire in the home. The registered person must make sure that hot water accessible to people living in the home is maintained close to and not exceeding 43°C to minimise the risk of scalding. Timescale for action 26/08/08 2 OP18 13(6) 26/08/08 3 OP19 23(4) 26/08/08 4 OP25 13(4) 14/10/08 Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 28 5 OP25 13(4) 6 OP27 18(1) 7 OP36 18(2) The registered person must make sure that radiators have guaranteed low temperature surfaces or are guarded to protect people from accidental injury. The registered person must make sure that there are sufficient staff on duty to meet peoples needs. The residential forum guidelines must be correctly applied to include those who require special assistance and difficulties in relation to the layout of the home to calculate the care hours required. The registered person must make sure that all of the care staff receive the recommended minimum of six formal recorded supervision periods per year (pro-rata) to ensure that they understand their roles and to identify any training needs that they may have. (The previous timescale of 28/02/08 was not met) 14/10/08 14/10/08 01/12/08 Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 29 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 3 4 Refer to Standard OP18 OP19 OP26 OP33 Good Practice Recommendations The registered person should make sure that staff receive annual refresher training in safeguarding procedures. The registered person should repair the ceiling paper in bedroom 6. The registered person should make sure that carpets in rooms 19 and 20 are cleaned or replaced if staining cannot be removed. The registered person should ensure that the quality monitoring systems are further developed and improved to ensure that the home continues to develop; and improve and that procedures in areas such as medication and health and safety are monitored effectively. The registered person should ensure that there are systems in place for staff to report health and safety or maintenance issues. 5 OP38 Orchard Court Care Home DS0000002869.V370798.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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