Inspection on 10/02/06 for Orchard House

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orchard House 22/10/08

Orchard House 28/09/07

Orchard House 07/12/06

Orchard House 04/11/05

Orchard House 10/02/05

Orchard House 04/06/04

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

CARE HOME ADULTS 18-65 Orchard House 92 Brookfield Road Bedford MK41 9LJ Lead Inspector Rachel Geary Unannounced Inspection 10th February 2006 11:50 Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 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 House DS0000033039.V279961.R01.S.doc Version 5.1 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 House DS0000033039.V279961.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Orchard House Address 92 Brookfield Road Bedford MK41 9LJ 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) 01234 363222 Bedfordshire County Council Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Maximum number of service users: 4 Gender: Male & Female Age range: 18 - 65 years Category: Learning Disability (LD) Period of stay: Respite only - up to a maximum of 6 weeks Until reprovision of this service takes place, the premises must be safe, and meet service users’ individual and collective needs 4th November 2005 Date of last inspection Brief Description of the Service: Orchard House is a respite service located in Bedford. The accommodation and grounds are owned and maintained by Aldwyck Housing Association, with Bedfordshire County Council providing the staffing and care support. The long-term plan for this service is reprovision. This is because the building does not meet the National Minimum Standards (NMS) for Younger Adults (18-65) environmental requirements. It is hoped that the service will remain in the local area, but at the time of this inspection, there were still no definite timescales for this to take place. The accommodation comprises of a bungalow, which is intended to provide respite care for up to 4 adults with learning disabilities at any one time. Stays are limited to a maximum of six weeks. There are four single bedrooms, a shared kitchen, bathroom, separate toilet, laundry area, and a living/dining area. The accommodation would not meet the needs of all individuals with a physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. There is parking to the front of the property, and there is also a small garden area. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, although some short notice was provided to the manager to ensure that certain records were available. The inspection took place from 11:50 am to 18:10 pm. The inspector met one service user, spoke to staff on duty including the manager and resource manager, observed practice, looked at records, and had a partial tour of the premises. The manager said that she was in the process of reviewing the number of service users who currently use the respite service at Orchard House. At the time of writing, it was thought to be approximately 35, with 4-5 new referrals. During this inspection, the hot water stopped working in the home. In addition, a new member of staff came in to meet the manager and start her induction. The manager and resource manager were observed to act professionally throughout this eventful shift, and dealt appropriately with matters as they arose. The day after this inspection, a decision was made to temporarily close the respite unit because the situation with the hot water had not yet been remedied. Some concerns are therefore raised with regard to the housing association response times. What the service does well: What has improved since the last inspection? What they could do better: Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 6 There are still lots of things that could be done to improve the service that is provided. The manager and resource manager acknowledged this during this inspection. There was also evidence that the home’s management had undertaken their own review of the service being provided at Orchard House. As a result, some proactive measures had already been put into place to address some of the service deficits. However, the timescales for a number of the previous inspection requirements have not been met, and have now expired. Revised timescales have not been given within this report. It is paramount that these are addressed as a matter of urgency, or the Commission for Social Care Inspection will be minded to take further action in order to bring about compliance, in accordance with the legal responsibilities of the Registered Provider. Some specific improvements that are required are: improving information for service users and making this user friendly, reviewing and updating all the care plans, carrying out regular fire alarm tests, training all the staff to administer medication and, allowing service users to administer their own where possible. In addition, improvements are needed regarding staff recruitment and training, to ensure the protection of service users, and to ensure that their individual and collective needs are met. Finally, the service must continue to develop current paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for care homes such as Orchard House. 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 House DS0000033039.V279961.R01.S.doc Version 5.1 Page 7 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 House DS0000033039.V279961.R01.S.doc Version 5.1 Page 8 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, 4 and 5. There is still insufficient information, specifically for service users, so that they can be clear about the service being provided at Orchard House. EVIDENCE: The home’s Statement of Purpose (SoP) had been updated since the last inspection. It contained the majority of the required information, but some elements of Schedule 1 of the Care Homes Regulations 2001, were still missing. It was said that the Service User Guide (SUG) was in the process of being updated. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 9 The assessment process for one new service user was looked at. The person had been due to come to the respite unit during this inspection, but had cancelled at the last minute. The manager had completed a comprehensive healthcare and social care assessment, and there was evidence that this information had been discussed with the service user and their parent. This information had then been used to develop a care plan for the service user. There was no evidence that the home had obtained a summary of the person’s care management assessment. Records indicated that the person had stayed over night at the home twice – once as a trial visit, and once as a planned visit. Limited information had been recorded about the person’s skill levels and abilities during these stays. Individual contracts for service users were still not in place at the time of this inspection. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 10 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 and 9. There is evidence that improvements are taking place with regard to reviewing and updating service user care plans. However, at the time of writing, care plans and risk assessments would not enable staff to meet all service users’ holistic needs and aspirations. Neither do they adequately promote opportunities for service users to build on their independent living skills. EVIDENCE: Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 11 The care plan for a new service user contained basic information however, this did link to information gained through the assessment process. It was said that because the person had only stayed at Orchard House twice before, that additional information would be added as required. No risk assessments were found for this person, and there were no guidelines for managing specific needs (in this case, autism). Care Plans were not user friendly. There was evidence that service user preferences regarding routines and dayto-day living, were being recorded within their care plans. And, an agency member of staff demonstrated a good awareness of one service user, based on knowledge of the person’s care plan. It was discussed that 11 care plans had been revised and updated in the previous week. The resource manager said that all plans would be complete by the end of February 2006. The manager said that care plans were being shared with service users and their families, to ensure the accuracy of information being held about each person. Photos of service users were still not being held on file as required however, the manager was in the process of organising this. Copies of the most recent review minutes were not available for one service user. It was discussed that a number of service user reviews had taken place the previous month, but that there was still a backlog. The resource manager said that in the future this would improve, because the respite service would be taking the lead in arranging reviews for respite service users. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 12 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, 14, 15, 16 and 17. Some good progress has been made with regard to enabling service users to participate in daily living activities, and accessing local community facilities. EVIDENCE: Due to the nature of the service, the service users’ main educational/occupational needs, are supported by their families/main carers. Care plans still contained limited information about independent living skills however, there was evidence that opportunities for, and the recording of, leisure and independent living skill activities, had improved since the last inspection. Recorded activities included going out to the pub, grocery shopping, cinema, making packed lunches, baking a cake and craft work including making a user-friendly complaints poster for the bungalow. It was said that staff supported service users to access local transport, including the ‘Dart’ bus. There was evidence that staff maintained regular contact with relatives/representatives of service users. Comments and required actions were being recorded. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 13 Prior to this inspection, a BCC resource manager shared information regarding an easy to read draft ‘Personal Relationships’ policy with the inspector. It was discussed on this occasion that when finalised, the policy would be adopted by all BCC adult learning disability services, as relevant. There was evidence that service users’ rights and choices are respected. Menu planning took place during this inspection. Pictures of ingredients and meals were shown to the service user to help him decide which meals they wanted for the duration of their stay. There had been plans for the service user to go food shopping afterwards, but because of problems with the hot water (see ‘environment’ section of this report), this was cancelled, and a member of staff went out to buy food for the weekend. A user-friendly shopping list and menu had been adopted by the home. The manager said that these had proved to be a success with service users, and that she had had a number of requests to add new items to the shopping list. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 14 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 and 20. Some good progress is being made to address the on going deficits regarding medication administration and self-administration within the respite unit. EVIDENCE: Staff were observed treating service users with respect, and providing appropriate support, in a manner that encouraged service users to maintain their own independence. Due to the nature of the service, the majority of service users’ health needs are supported by their families/main carers. It was discussed that the home could support these as required. It was previously reported that one service user had said that he was not allowed to administer his own medication when staying at Orchard House, but that this was something that he did independently when he was at home. There was evidence that this preference had been noted within his care plan, and it was said that individual medicine cabinets had been ordered to be fitted in service user bedrooms. However, due to the current organisational policy regarding medication administration, and a lack of training for agency staff, service users were still not able to self administer at the time of this inspection. It was said that once these issues had been addressed, service Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 15 users would be assessed by a community nurse regarding their ability to selfadminister. The responsible individual for this service, Kate Walker, had developed a clear and comprehensive draft policy specific to the respite service which set out that there was an ‘ongoing dialogue between Operations Managers and Agency Managers about the need for agency staff to receive basic medication administration training’, and that ‘agency staff who are requested to administer medications will also be subjected to Beds County Council medication training and a pharmacy session’. A BCC operations manager recently confirmed that a number of BCC permanent staff were due to start a 21-week distant learning course entitled ‘The Certificate for Safe Handling of Medications’. It was said that in the first instance, permanent staff would support respite medication training, but that there were plans for Paveys agency staff, to access the same training. Eventually, it is the intention that all respite staff will be trained. The manager said on this occasion that 5 staff were being put forward for this training. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 16 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): 23. There is evidence that appropriate arrangements are in place for protecting service users from abuse. EVIDENCE: A user-friendly complaints procedure had been developed since the last inspection, and was on display in the entrance hall. It was said that service users had helped to make this. There was evidence that staff had received training regarding the protection of vulnerable adults (POVA), and that appropriate organisational and local policies were in place. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 17 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. The environment does not completely meet the environmental requirements of the National Minimum Standards (NMS) for Younger Adults (18-65), although plans are in hand to provide a more homely place to stay. EVIDENCE: As previously reported, the respite bungalow is part of the existing Orchard House service. The unit operates in conjunction with Aldwyck Housing Association, who are responsible for the maintenance and upkeep of the building, fabrics and furnishings. The accommodation does not adequately meet the NMS environmental requirements, and would also not meet the needs of all individuals with a physical disability. To this end, the home’s long term plan is reprovision. At the time of this inspection, there were still no definite plans for this to take place. In the interim, the CSCI has agreed that the environment must at a minimum, meet the needs of the service users. And, the home’s conditions of registration have been updated accordingly. The new certificate of registration was not yet on display. A number of improvements had been made to the building since the last inspection. These include: the installation of a specialist bath with shower Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 18 facility, a handbasin within the laundry room, a new carpet in the living room, fitting covers to some of the radiators, and fitting new kitchen cupboards. The boxing in of pipework in the toilet remained outstanding. In addition, it was noted on this occasion, that the lounge and bathroom were in need of some redecoration. The manager said that a bathroom cabinet with a mirror had been purchased, and was waiting to be put up. Concerns about the hot water pressure and temperature in the bungalow have previously been reported. On this occasion, the provision of hot water was erratic, and then completely stopped. Attempts were made by the manager and resource manager to get someone from the housing association to fix it, but this did not happen, and a decision was made to close the service the following morning. An email received from the manager stated that by 13.2.06, a new pump had been fitted, and that the hot water was running again. Some picture frames had been put up in the corridor of the bungalow. It was said that these were for ready service users’ artwork, and to create a more ‘homely’ feel. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 19 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): 34 and 35. Continuing inconsistencies in the information held on staff files calls into question the homes commitment to providing suitable staff to meet the needs of service users. EVIDENCE: As previously reported, the home was using agency staff (Paveys) to supplement a small core group of permanent staff. At the time of this inspection, a second agency (Blue Arrow) was also being used. The resource manager said that plans were in hand to recruit more permanent staff. Agency staff profiles were being kept in the home. Profiles provided by Blue Arrow agency did not contain the required information. This was raised previously with the organisation during an inspection of another BCC service. No profile was found for the agency member of staff on duty during this inspection. The manager immediately requested a copy, which was faxed through by the agency. The photo was not clear. There was no evidence that the manager had verified information held about agency staff. Records for permanent staff were still being held centrally. It was discussed that the CSCI has recently developed some new guidance, which allows for greater flexibility about the storage of staff vetting records, subject to agreement with the local CSCI office. Once an agreement has been reached, Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 20 certain records may then be held centrally rather than in the care home. At the time of writing, an agreement had not yet been set up. Individual staff training and development plans had been started for some of the permanent staff. There was evidence that the manager had requested staff bring in copies of course certificates, but these were not on file for 2 staff. Some training was out of date and refresher courses were required. Assessment information for a new service user recorded that the person had autism. There was no evidence that any staff had been trained to reflect this need, and autism was not included within the specialist training section on the training and development plans. There was no evidence of training for some agency staff, or that they had completed the required LDAF (learning disability award framework) induction programme. In addition, it was also not clear how many of the agency staff had completed a relevant NVQ. The manager had arranged to meet with a new night member of staff, during this inspection, as part of the induction process. It was not clear if the member of staff, who did not an NVQ qualification, had already completed a LDAF induction programme through previous employment. The manager said that the person had been recruited prior to her own appointment, so she had not been able to establish this information earlier on, as would be usual. The manager said that she had received an email from the organisation’s HR department, outlining that the person’s checks had come through – but it did not detail the training information. It was discussed that this information should be established prior to a member of staff starting work, so that induction programmes can be completed in the required timescales. The manager said that she intended to revisit the in-house induction programme with all staff to ensure consistency of knowledge. A staff-meeting folder indicated that there had not been a meeting in the unit since 27.9.05. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 21 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, and 42. Despite there still being limited progress in some important areas, there was evidence on this occasion, that the home’s management had undertaken an open and objective review of the service being provided at Orchard House. As a consequence some proactive measures have been implemented to address service deficits, and to bring about the required improvements. The inspector has previously advised that given the numbers of service users, and the amount of work required to address ongoing service deficits, that the part time status of the manager should be kept under review in the long term. Findings from this inspection have not changed this view. EVIDENCE: Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 22 Since the last inspection of this service, the manager, Angela Bradley, had submitted an application to register with the CSCI. This was still being processed at the time of writing. The manager said that she had completed an NVQ 3, and was hoping to start the required NVQ 4 in Care and Management qualifications, in the near future. No provider reports, as required by regulation 26 of the Care Homes Regulations 2001, had been received by the Commission in respect of this home, since the last inspection. However, regular communication between the responsible individual and inspector had taken place. Minutes of a meeting held by the manager, resource manager and responsible individual for this service were seen on this occasion. The purpose of the meeting was to discuss progress and service developments in line with CSCI standards and requirements. The minutes acknowledged that some agreed action timescales from the last CSCI inspection report had slipped. It was suggested that this was in part due to a lack of management time. As a result, the manager’s hours were increased from 25 per week to 37 for 3 months, commencing 16.1.06. The resource manager confirmed that the situation would be kept under the review. In addition, unit manager peer meetings had been set up to share good practice with other similar services. There was evidence that feedback questionnaires were being sent out to service users however, the results of this process had not yet been analysed and used as part of the required quality assurance and monitoring process. The manager said that a number of local policies were in place, or were in the process of being drawn up. The records for the testing of fire alarms and emergency lighting were unclear. As previously reported, the system is linked to the adjacent supported living service, and records did not make clear the location of the call points and equipment being tested. There was evidence that tests were still not taking place at the required intervals, and no records were found for fire drills. No further concerns relating to health and safety were noted during this inspection. The resource manager said that a business and financial plan for the home was in the process of being developed. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 23 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 2 2 3 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 1 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 N/A 1 X 3 X 2 X X 2 X Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 24 YES 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 YA5 Regulation 5 Requirement Ensure that contracts/ terms and conditions are in place for all service users, that include all elements of NMS 5. (Previous timescale of 30/6/05 not met). Ensure that information and documents in respect of person’s carrying on, managing or working in the home (see Schedule 2 of the Care Homes Regulations 2001), are kept in the home, and open to inspection at all times. Note that from 26/7/04 Schedule 2 has been updated within the amended Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. (Previous timescale of 30/4/05 not met). *Also, from November 2005, new CSCI guidance is in place regarding the storage and retention of staff vetting records. Arrangements should now be made in line with this guidance. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 25 Timescale for action 31/01/06 2 YA34 17 14/04/06 3 YA6 15 4 YA9 13 5 YA35YA32 18 6 YA24YA24 23 7 YA41 15 and 17 8 YA20 13 10 YA40 17 Ensure that care plans are completed for all service users that meet the requirements of NMS 6. (Previous timescales of 30/11/04 and 30/6/05 not met). Ensure that individual risk assessments are updated and completed in line with the requirements of NMS 9. (Previous timescales of 30/11/03 and 30/6/05 not met). Ensure that there is a training and development programme, (for all staff) which incorporates induction, mandatory, specialisttraining and NVQ courses/qualifications. (Previous timescale of 30/4/05 not met). Ensure that regular fire alarm and emergency lighting testing is carried out. Also, regular planned fire drills (specifically for the respite bungalow). (Previous timescales of 23/7/04 and 15/3/05 not met). Ensure that all aspects of Schedule 3 of the Care Homes Regulations 2001, are maintained in respect of all service users. (Previous timescales of 6/8/04 and 30/6/05 not met). Ensure that all staff working in the home receive medication training. (Previous timescales of 31/8/04 and 30/4/05 not met). Ensure that the home’s written policies and procedures are specific to the respite service, and cover all the topics as set out in Appendix 2 of the NMS for Younger Adults. Please also ensure that the death of a service user policy is updated to include the additions listed in the previous report. (Previous timescale of 30/4/05 31/01/06 31/01/06 31/12/05 30/11/05 31/01/06 31/12/05 31/01/06 Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 26 given). 11 YA39 24 Not assessed on this occasion. Ensure that a quality assurance and monitoring system is in place for the home, which fully meets the requirements as set out in standard 39 of the National Minimum Standards for Younger Adults. (Previous timescale of 30/4/05 not met). Produce a business and financial plan for the home and the service, which is open to inspection and reviewed annually. (Previous timescale of 30/4/05 not met). Update the Service User Guide so that it meets the requirements of NMS 1 for Younger Adults (18-65), and regulation 5 of the Care Homes Regulations 2001. 31/01/06 12 YA43 25 31/01/06 13 YA1 5 31/12/05 14 YA20 13 15 YA39 26 Please forward a copy to the CSCI on completion. Ensure that service users retain, 15/12/05 administer, and control their own medication where appropriate, and are protected by the homes policies and procedures for dealing with medicines. Ensure that monthly 31/12/05 unannounced visits are carried out in accordance with regulation 26 of the Care Homes Regulations 2001, and that reports from these visits are sent to the CSCI on a regular basis. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 27 No. 1. 2. Refer to Good Practice Recommendations Standard YA6YA5YA3YA1 Produce information for service users, i.e. care plans, contracts, Service User Guide etc, in a more userfriendly format. (This is a recommendation from the 4/6/04 and 10/2/05 reports). YA8YA3 Introduce a user-friendly system in the home so that service users know in advance which staff are planned to work with them. (This is a recommendation from the 4/6/04 and 10/2/05 reports). Orchard House DS0000033039.V279961.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 House DS0000033039.V279961.R01.S.doc Version 5.1 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. 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