Inspection on 26/09/06 for Orchard Hill

This inspection was carried out on 26th September 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Orchard Hill 05/06/07

Orchard Hill 04/10/05

Orchard Hill 01/08/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Orchard Hill 100 Orchard Hill Little Billing Northampton Northants NN3 9AG Lead Inspector Stephanie Vaughan Unannounced Inspection 26th September 2006 08:30 Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 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 Hill DS0000063584.V313112.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 Adults 18-65. 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 Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Hill Address 100 Orchard Hill Little Billing Northampton Northants NN3 9AG 01604 403602 01604 403602 manager.orchardhill@tracscare.co.uk suehullin@tracscare.co.uk TRACS 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) Bridget Adeseko Care Home 4 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (4) of places Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one falling within category MD, Mendal Disorder should be admitted into Orchard Hill unless that person also falls within the category LD ie dual disability The maximum number of persons to be accommodated at Orchard Hill is 4 4th October 2005 Date of last inspection Brief Description of the Service: 100 Orchard Hill is a detached Home which provides personal care and support to 4 service users who require care due to a Learning Disability, some of whom may have an additional Mental Health Disorder. This is one of five homes run by the providers Compass Care and benefits from the support of a wider organisation. The home is situated near to a large shopping centre and has good transport links to other areas of Northampton. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to this statutory inspection, a period of two hours was spent in preparation. This comprised reviewing previous inspection reports, associated requirements and recommendations; the service history, risk assessment and the recent Registration Report. The inspector was unable to analyse residents Comment Cards or the Pre Inspection Questionnaire prior to the inspection. On enquiry it was established that the Registered Manager had returned this information at the beginning of August, however this has not been received by the Commission and has therefore probably been lost in the post. Since the last inspection the Commission have received no complaints about the home. However has received one Safeguarding Adults referral, which is addressed in the main body of the report. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. This site visit to the home was conducted over a period of five hours during which the inspector made observations and spoke to residents and staff. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of two residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The Registered Manager was present during most of this visit. The current fees range form £1,800 to £2,000 per week with extra charges for personal transport toiletries and personal items such as spectacles. The Certificate of Registration was displayed and is accurate and up to date. What the service does well: Residents say that they were happy with the way that their move to the home was arranged. The staff make sure that they have the right information and are able to provide the right care for residents who might wish to live there. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 6 The management are working with Speech and Language Therapists to develop a range of care plans to enable residents to have a greater input into the care planning process. Residents are able to make decisions for themselves, to be involved in decisions about the running of the home and to take responsibility for personal tasks. Residents are involved in a wide rage of activities, which allow them to make the most of their abilities and lead interesting and active lifestyles. Residents are supported to develop their education, previous interests and work opportunities. Residents said that the staff were nice to them and that they had privacy in the home. Residents said that the food was good and that they had the things that they liked and allowed them to have a healthy balanced diet. When needed residents are able to see the right doctors, nurses and specialists Resident’s cultural and religious needs are met. Medication is given to residents properly and when mistakes occur the management take the right action. Staff are trained and take the right action to protect residents from abuse. All areas of the home are clean and comfortable; residents are able to have their own property there. There are enough staff working in the home to look after the residents properly. The managers make sure that the people who work there have the right checks and training. What has improved since the last inspection? New residents have the right information to help them decide whether they would like to live in this home. The staff write good plans of care that make sure that the residents are cared for properly and that any risks are managed. These are checked regularly to make sure that they still contain the right information. Residents now have the right checks done to make sure that their health is looked after. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 7 Individual plans of care now contain the right information about the resident’s wishes on growing old and how they wish to be cared for if they are ill. Complaints are managed well and staff have the right training to make sure that they treat them properly. The new manager is working to make sure that the right checks are done to make sure that the home is managed well and the residents are satisfied. Care provided by the service is highly individualised and residents are consulted on a day-by-day basis as to their views and wishes. As such the service demonstrates an ability to address Equality and Diversity. The inside of the home is safe. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Admission processes are managed well and residents have the right information to enable them to make informed choices. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: Following a Requirement made at the previous inspection the Statement of Purpose has been reviewed and reissued. It now reflects the current service provided and includes details of the newly registered manager. This Requirement is therefore met. A new resident was case tracked and evidence included in the individual plans of care indicated that full assessments are obtained from the placing authorities and that these are used to develop appropriate individual plans of care. The plans are comprehensive and indicate that the service is able to meet the resident’s needs. The resident confirmed that he had been provided with appropriate information about the home and had opportunities to visit; meet fellow residents and the staff before deciding whether he would like to live there. Following a Requirement made at the last inspection, residents contracts have been reissued these now contain up to date information about the fees and are signed by the residents themselves. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 10 Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Systems within the service ensure that the needs and choices of the individual residents are met. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: Following a Requirement made at the last inspection the individual plans of care have been completely revised. A new format has been developed which enables the right information to be recorded, in a clear and detailed way. The plans are developed from the assessments conducted by the placing authorities and contain detailed instruction to staff about all aspects of health, personal, social and emotional care. This Requirement is therefore met Following a previous requirement individual plans of care now contain robust and comprehensive assessments for the management of the risks for the individual residents. This Requirement is therefore met. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 12 Any restrictions placed on residents are in their own best interests and are supported by appropriate explanation to the resident concerned and are appropriately recorded. Following a previous Requirement, Individual plans of care now contain detailed instruction about the support that the individual residents need in the management of challenging behaviour. Individual plans of care do not currently evidence that residents or their representatives are involved in the care planning process or review. On further enquiry it was established that the management are currently working with Speech and Language Therapists to develop a range of graphic care plans to enable residents to have a greater understanding and participation in the process. A previous Requirement was made regarding situations where a resident’s care deviates from that required by the placing authority the written authorisation must be obtained and included within the individual plan of care. Although the resident concerned has transferred to another home within the group, the Commission have been supplied with evidence that the previous Registered Manager has addressed this. This Requirement has therefore been met. Individual plans of care are reviewed on a regular basis and residents have access to key workers Residents are supported to maintain their rights within the constraints of their placing authority assessments and assessed risks. Residents confirmed that they are supported to make decisions in their daily lives regarding the running of the home, their personal activities and relationships. Residents are supported to maximise their independence and have robust risk management systems in place to support them to do this, examples include preparation of their own food and domestic responsibilities. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17 Residents are involved in a wide rage of activities, which enable them to achieve their potential and lead interesting and active lifestyles. The quality in this outcome area is excellent, this judgement has been made using available evidence including a visit to the service EVIDENCE: Residents are involved in a wide rage of activities, which enable them to achieve their potential and lead interesting and active lifestyles. Each of the residents has their own personalised activities programme. Staff have worked with Speech and Language Therapists to develop a graphic format, which increases the residents independence by being able to interpret their own programme. Residents have access to a range of educational activities including attendance at the local college for a variety of subjects. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 14 In addition the organisation also supports residents to improve their numeracy and literacy skills by the provision of external personal tutors. Staff support residents with the associated homework. One of the residents confirmed that he has been supported to continue with his previous interests and activities following recent admission to Orchard Hill. Residents are able to access part time employment through attendance at supported work placements. Residents have access to a wide range of facilities within the community to assist them in the maintenance of a healthy lifestyle. These include regular attendance at the local swimming pool and gymnasium. Residents are supported to access other leisure facilities such as the local library, cinema, shops clubs and pubs. Residents are supported to maintain appropriate relationships within the home and with other residents from homes within the group through the arrangement of regular social activities. Residents conformed that they are able to maintain links with their families and friends. This is by receiving visitors into the home or by their visiting relatives and friends. Daily routines are managed well; residents are clear about their activities and responsibilities and were able to confirm their satisfaction with the way that they are supported. Residents confirmed that their privacy is respected and this was evident from information within the individual plans of care. Residents had given signed consent for the staff to enter their rooms to provide them with support with their domestic chores. Residents rooms have privacy locks installed and residents confirmed that they had keys to their rooms. Staff were seen to relate well to residents, being knowledgeable about their preferences, needs and individual personalities. Residents were seen to move about the home freely and to have unrestricted access to the grounds. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 15 Individual plans of care contain appropriate documentation to balance the individual’s rights to take risks against the health and safety risks involved. Examples include activities such as smoking and use of alcohol in both circumstances this appears to be well managed. Residents confirmed that they were able to contribute to the menu planning process and other kitchen activities such as the laying of the table and clearing away. These additional activities are included in a graphic chart maintained within the kitchen. Residents stated that they enjoyed being involved in these routine tasks. Residents were also able to confirm that they had a variety of meals that reflected their own preferences, that the standard of the food was good and that meals were of adequate proportion. The menu was viewed and seen to offer a varied and balanced diet. One resident of Persian origin is supported to shop for foods that are appropriate to his preferences and culture. The lunchtime service was viewed and residents were seen to have individual supervised access to the kitchen for the preparation of their own toasted sandwich and vegetables. Food was eaten in the pleasant dining area in a relaxed and friendly atmosphere. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 & 21 Residents are supported to maintain their health and personal care. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: Following a previous Requirement regarding the failure to monitor and record a resident’s medical condition as directed by the medical practitioner, a review of the specific residents records was conducted. These are much improved with only very occasional gaps. This Requirement is therefore met. However it was established that on these occasions the tests were not conducted due to the mental state of the resident at the time and who had chosen to go to bed. Following further discussion it was agreed that when these tests were not conducted that the reason for not doing so would in future be recorded. The Registered Manager is mindful that these tests need to be conducted at least once a day and has agreed to conduct a risk assessment to demonstrate Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 17 what action would need to be taken if they were unable to do this and also taking into account the level of the last available reading. Residents confirmed that that staff provided sensitive support to enable them to maintain their personal care. Individual plans of care provided detailed instruction to staff about the resident’s routines and preferences for all aspects of personal care. Residents appeared well presented Residents confirmed that they enjoyed good relationships with staff and had access to individual key workers. Discussion with the Registered Manager confirmed that management are mindful of the need to reflect the gender, race, religion and culture of the existing residents in their staffing. Attempts are ongoing to obtain access to representatives and advocacy services from the Persian Community to meet the needs of one resident. Access to the religious community has been offered but declined. Residents have access to a full range of health care services, including general practitioners, hospital consultants and psychiatrists. In addition residents have access to specialists such as dieticians, podiatrists and speech and language therapists. Health care is managed well and appropriate monitoring is conducted such as regular weights, eye tests and dental check ups. Evidence was seen that if health issues are identified that the appropriate referrals are made. Medication systems were reviewed and found to be in good order. Residents have approved homely remedies and a medication profile containing a photograph for identification purposes. A spot check was conducted and the Medication Administration Records were well maintained and seen to correspond with the medication that remained in the packaging indicating that the medication had been given as prescribed. The Registered Manager is proactive in the management of medication, conducting frequent medication audits and has introduced a colour coding system to ensure that medication is administered appropriately. The Commission have received a notification regarding a medication error that occurred in the home in April this year. A full investigation has been conducted and report has been received. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 18 The management have demonstrated that appropriate action was taken at the time of the error, with appropriate observation and guidance sought from the General Practitioner. The investigation resulted in the staff member responsible being provided with further training and continued supervision in the administration of medication. Staff files evidenced appropriate disciplinary action. Individual plans of care evidenced that residents are consulted about their views regarding aging, terminal care and death. The organisation has developed a comprehensive document to assist in the collection of this information. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Residents concerns are addressed and they are protected form abuse. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: A requirement was made as a result of the previous inspection regarding the outcome of a complaint investigation, which recommended further training and improved record keeping for senior staff. Personnel changes within the organisation mean that the inspector was unable to follow this up with the particular member of staff. However the complaints file was viewed and seen to contain one complaint for 2006. This had been appropriately recorded, investigated, responded to and filed. Discussion with staff indicated that they were aware of their personal responsibilities regarding the management of complaints in line with the corporate complaints policy Residents have access to a complaints policy, which is included in the individual plans of care. The Commission have received no complaints about this service since the last inspection. This Requirement is therefore met. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 20 The Commission have received one serious Safeguarding Adults notification since the last inspection. The incident involved two residents, one being from another home within the organisation. Staff and management dealt with the incident appropriately with referrals being made to the appropriate authorities, in line with the local Safeguarding Adults guidelines. As a result support and supervision have been increased and risk assessments have been revised. Staff were able to confirm that they had had recent training in the Safeguarding of Adults and were able to demonstrate their knowledge to the inspector. The management holds small amounts of money for residents, this is stored appropriately and receipts and records are maintained. A spot check of one of the resident’s money was conducted, this was found to be in excess of the recorded balance by 21 pence. The Registered Manager initiated an investigation during the course of the inspection. However individual plans of care contain sensitive information about the residents’ finances. This includes details of bank and building society accounts such as the account numbers and the balances. This was discussed with the Registered Manager who agreed to store these records in a more secure environment to ensure that residents are protected from potential identity and financial fraud. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The premises are suitable for the stated purposes, being homely, safe and well maintained. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: The premises are suitable for their stated purpose and are accessible to a good range of local amenities. Resident’s rooms were fitted with appropriate furnishings and fittings such as window restrictors and privacy locks. Resident’s rooms are personalised with their own property. The home is clean, comfortable, well furnished and well maintained. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Residents are in safe hands at all times. The quality in this outcome area is good; this judgement has been made using available evidence including a visit to the service EVIDENCE: Staffing levels in the home are good and comprise four staff throughout the day, including the Registered Manager with one waking member of staff at night. The use of agency staff has been considerably reduced by the increase of permanent staffing levels. The organisation has a staff bank, members of which are known to the residents and are used as if required. Staff confirmed that the staff morale had been much increased by the improved staffing levels and that the continuity had resulted in good outcomes for residents. Staff files evidenced good recruitment procedures, including appropriate references and Criminal Records Bureau Clearances. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 23 Staff confirmed access to appropriate mandatory training including Fire Safety, Basic Food Hygiene, Safe Administration of Medication, Movement and Handling, Infection Control and Safeguarding Adults. Pre existing staff were able to confirm that they had undertaken training in National Vocational Qualification in Care level 2 and the Learning Disability Award Framework. New staff that had been recruited from oversees were able to confirm access to appropriate induction training and training to support them in the development of their English language. All staff have received training in the management of challenging behaviour focusing on de-escalation techniques. Staff files evidenced that systems for appropriate staff supervision and appraisal are in place and that appropriate disciplinary procedures are followed when necessary. Staff files evidenced appropriate documentation such as job descriptions and contracts and Home Office authority. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 The service is generally managed well, however some improvement to the exterior of the premises is required to ensure the health and safety of residents. The quality in this outcome area is adequate, this judgement has been made using available evidence including a visit to the service EVIDENCE: The current manager has been in post approximately six months and has recently become Registered. She is qualified, experienced and competent to fulfil the role of Registered Manager. Both residents and staff spoke well of the Registered Manager saying that she was supportive and had made improvements to the home that benefit both residents and staff. Quality assurance systems are being developed and include regular internal audits of medication, Pharmacists Audits, residents’ money and audits of individual plans of care. Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 25 The Management aim to conduct annual satisfaction surveys to establish resident’s views and this has yet to be commenced for this year. However care provided by the service is highly individualised and residents are consulted on a day-by-day basis as to their views and wishes. As such the service demonstrates an ability to address Equality and Diversity issues for residents living in the home. The corporate policies and procedures continue to be reviewed to bring the pre existing policies in line with those of the new organisation. Safe working practices are promoted through the provision of staff recruitment, training, supervision and the robust management of risk. Individual plans of care evidenced the appropriate management of accidents and incidents. No hazards were identified within the home. However the tarmac on the front drive is disintegrating near to the entrances to the home. This presents a significant trip hazard to the residents some of whom are already vulnerable to the risks of falls. Orchard Hill DS0000063584.V313112.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 3 X 2 X Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13.4 Requirement The hard surfaces surrounding the exterior of the building must be made safe Timescale for action 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Orchard Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Hill DS0000063584.V313112.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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