Inspection on 22/11/06 for Orchard Leigh

This inspection was carried out on 22nd November 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Orchard Leigh 02/11/05

Orchard Leigh 31/05/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Orchard Leigh Hayden Road Cheltenham Gloucestershire GL51 0SN Lead Inspector Kath Houson Key Unannounced Inspection 22nd November 2006 09:30 Orchard Leigh DS0000062769.V319844.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 Leigh DS0000062769.V319844.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 Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Leigh Address Hayden Road Cheltenham Gloucestershire GL51 0SN 01242 523848 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) www.milburycare.com Milbury Care Services To be Appointed Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care and accommodation for up to eight service users with a learning disability, but may also accommodate service users with associated physical disabilities and sensory impairments provided that their primary needs relate to learning disability. One named service user accommodated who is over the age of 65 years. For one named service user with a mental health condition to remain accommodated at Orchard Leigh. 2nd November 2005 2. 3. Date of last inspection Brief Description of the Service: Orchard Leigh is a care home for up to eight adults with learning disabilities. The home is in the process of changing their conditions of registration to include mental health and learning disabilities. The change with the variation would mean that the service could accept referrals to include those with mental health conditions. The home provides spacious single rooms, each with en-suite facilities. The house is detached with two floors; there is no lift available as the staircase is too narrow. The home is situated on the edge of Cheltenham, with easy access and is close to shops in Swindon Village in the Cheltenham area. The facilities within the community include a supermarket, a pub, retail shopping area and is close to bus routes to Tewkesbury and Gloucester. The home was able to produce a copy of the Statement of Purpose. The current charges are £1350-£1950 that are charged by the home and is dependant on items which maybe built into service users’ care package. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The unannounced inspection took place one day in November 2006. The manager was available throughout the inspection and was able to assist in a positive manner creating a working partnership with the Commission for Social Care Inspection (CSCI) Twenty two-key and two-non key standards were examined. This included an examination of documentation; three service users were case tracked (which is a method used to carefully examine and link various aspects of service user’s care within the home). A tour of the environment is to explore the physical side and obtain a visual account of the home. A short discussion with a service user and a member of staff formed part of the inspection. A short succinct feedback was given to conclude the inspection visit. The inspector would like to extend her thanks to the service users, staff and management for their assistance with the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home will need to review its secondary dispensing methods of medication to minimise the potential for error whilst service users’ are on home visits during the weekend. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 6 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 Leigh DS0000062769.V319844.R01.S.doc Version 5.2 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 Leigh DS0000062769.V319844.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions process is considerate to the needs of the potential service users’ and takes into account the compatibility of the existing service users’ in the home. Potential service users’ have a thorough assessment procedure that ensures that only individuals whose needs can be met are admitted into the home. EVIDENCE: The home’s admissions process for this service is good and carefully thought through. The potential individuals are assessed to ensure that a positive match and compatibility with the existing service users are met. The acting manager paid particular emphasis to the importance of the existing service users’ to ensure that service users continue to be comfortable with new admissions into the home. The acting manger takes steps to involve existing service users in this process. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 9 The manager additionally, addresses potential service users’ needs with the home’s house rules in which the importance is placed on verbal communication in an attempt to prevent and manage challenging behaviour. Service users’ have described the home as “peaceful and quiet.” The home does have a philosophy and provides care according to service users’ needs assessments. All assessments are carried out by the manager and deputy manager and involve a number of other health professionals if necessary. The new assessment form was seen as evidence and the form is detailed to include; physical and medical needs, mental health, specific care requirements, environmental needs, emotional/spiritual and psychological needs, social living skills, healthcare needs, transport needs, behavioural needs, cultural needs, interests and aspirations of goals and personal expressed choice needs. If the individual has difficulties with communication then an advocate/relative is encouraged to express a view. As an additional part of the admissions procedure the manager expressed the need to encourage potential service users’ to experience an adequate spell of overnight stays. The main objective is for potential service users’ to gather their own information about the home and for the home to obtain knowledge about the service user’s routine. This may provide the manager the information required for compatibility. The home has additionally reviewed its condition of registration. The provider has decided that for the future, the need for further variations to include mental health conditions. This has been addressed with the CSCI Central Registration Team, details have been shared with the manager and the appropriate certificate will be issued in the near future. The potential service users’ are aware that the home provides a structured residential care package in a safe setting. There have been numerous meetings to discuss service user’s needs; such as service users’ abilities and the opportunity to provide skills assessment are part of the assessment procedure. This ensures that individual needs can be met once admission into the home has taken place. The care provided is dependent on personalised packages and additional items built into the care package are charged according to service user’s needs’. For instance if five days of day care is required a reduction in the fees are made. The home has included an individually written terms and conditions statement of terms and conditions for the home, which is placed in each service user file. The home was also able to provide a recent statement of purpose but the manager felt that the organisation’s address required changing to make this more up to date. Overall this service is good and continues to make improvements. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good frameworks in place to ensure that individual needs and choices are met. Service users are supported and encouraged to make decisions about their life within the care home. Service users’ are risk assessed to ensure that activities are performed safely. EVIDENCE: Three care plans were case tracked with one focused on the behavioural programme which is the management of challenging behaviour. Care plans appear to be documented well and contain appropriate guidance for staff to follow. There was evidence of regular reviews which can be seen as good Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 11 practice. The acting manager felt that the approach is to discuss with the service users’ any issues that need to be worked through for instance personal independence can be dealt with in a calm manner. This was then discussed with positive incentive agreed and support provided. This was evident in the management of challenging behaviour programme. The manager said that the main objective is to obtain a possible link are between the service user and events which may/may not affect the service user. It was evident that service users’ are aware that their needs are assessed and is reflected in their care plans, as service users’ were able to provide signatures. The home makes available a key worker system in which the key workers’ are allocated 1:1 time with service users’. The task ranges from discussing personal care to providing and supporting with external activities. The manager ensures that the rotas are centred on the service users’ needs. As part of this procedure the key workers’ were to write up a monthly report on the progress of service users’. In all cases the reports are used at the service user’s reviews with other health and social care professionals. Thus sharing information on service users’ progress and the reassessment of goal aspirations. Service users’ if required have a social diary in which entries can be made to inform staff of achieved goals and future plans. In some instances behavioural tasks are also included together with a response made by the service user. On examination there was detailed recording which can be seen as good practice. The home additionally, has internal reviews. Discussions are centred on changes and improvements for service users’ that is then incorporated into the care plans. This provides a continuous step-by-step approach and informs relevant representatives of progress. The manager has arranged for the home to have its own newspaper. This newspaper provides information about how service users’ spend their time. The manager was able to produce a copy of the newspaper “The Orchard Leigh Star” during the inspection. The copy was a prototype that contained information about service users’ activities. It was packed with detailed accounts of service user’s events. The plan is to produce a copy of the newspaper every three months and send it to families of service user’s. Verbal feedback from relatives about the newspaper has been positive and the home has taken steps to ensure that data protection has been maintained throughout. The home also has a staff suggestion book in which written comments can be entered with ideas which service users’ involvement with their key worker is creative and fulfilling. Such ideas include, college courses, places to visit, and outings. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good support has been provided to service users’ to participate in activities that reflect their interests and lifestyle. Diversity is encouraged and promoted so that service users’ have a wider experience of their environment. Service users are encouraged to participate in local community activities and have appropriate contact with family and friends external to the home. A balanced diet is provided which reflects choice and dietary preferences. EVIDENCE: The service user’s each have an individualised and structured activities programme. This was evident in the selected care plans that were case tracked. The manager is additionally given funds per month towards activities. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 13 The funds are spent on day centre sessions that are of benefit to the service users’. The monthly budget sheet was seen evidencing that the providers have allocated the funds to enhance service users independence. The home has good contact and links with the day centre and information shared between the home and day centre. This can be seen as good practice as it provides consistency of care and monitors service user’s progress. This additionally ensures that service user’s goal aspirations are met and discussed, enabling support to be provided. Activities include Matson House, music, and hiking. At Ellerslie Nursing home, service users participate in making Christmas decorations. Other activities also include going to the cinema, bowling, and a seasonal pantomime. Service users are also part of the local community and go out to the local pub and the local supermarket. As part of the behaviour management programme service users’ and key-workers combine efforts to change negative behaviour. This is achieved via positive reinforcement. The manager ensures that a wide range of choice is offered and increased links with other networks to ensure that choice is maintained. Activities, also taken place at Gloscat, the theatre and the cinema. For instance if service users’ have a particular liking for old black and white movies the home ensures that their choice is achieved and take steps to seek and find information about afternoon matinees. Additionally, the information gathered is added to the care plan to ensure that staff are provided with the information needed to provide good quality care. The home additionally ensures that diverse needs are met. All service users’ are supported to preserve their cultural identity and lifestyle. The home for instance is able to accommodate couples if necessary. The home has a very diverse staff team which would be of benefit to service users’. The manager is keen to widen the experience of all who participate in the service at Orchard Leigh. During a discussion with a member of staff it was evident that the staff address all service users’ and each other with consideration and respect. This was clear during the inspection when services users’ were appropriately addressed. The home has little occurrence of challenging behaviour from service users’ this reflection suggests that the compatibility factor has positive effects and benefits for service users’. This was also evident from comments made from service users “ I have no dislikes here” and “I have made friends with the other service users.” Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 14 The home provides a well balanced diet that is in a picture menu format. This was compiled with the assistance of the service users. The menu is planned using a number of pictures of food items in various categories. The chosen items for lunch for instance are then placed on a Velcro board. The concept is novel and creative and the food items are becoming extensive. This is good practice as this demonstrates inclusiveness of the home and the service users’ being a part of their home. A member of staff said during the inspection “that this is their home and we the staff are here to support.” This was evident in the manner and approach and the calmness of the home. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ receive necessary support with personal care, which promotes their health and well-being. Support is also provided with healthcare needs and is well recorded in care plans and monthly reports. Generally satisfactory arrangements are in place for safe handling of medication. The home is required to review its secondary dispensing arrangements in preparation for service users’ home visits. EVIDENCE: Selected care plans demonstrate that care is provided to service users’ who request assistance. This is a good approach and show that service users’ choose when to ask for support. There were some indication of individual preferences around routine and how care was provided. The staff team approach to service users is one of care, consideration and respect. This was Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 16 evident throughout the inspection. During a discussion with a member of staff, it was clear that knowledge and awareness of service user’s needs were understood. The care plans had detailed communication sheets that also provided clear guidelines. Thus respecting individual’s privacy and dignity. Healthcare records also provided evidence that service users’ were supported to access specialist services according to their needs. The rota is arranged around service user’s appointments. Care plans show that there are other inputs from other agencies, for instance dietician and or the Occupational Therapist that assist service user’s to develop other skills. The home utilises the help from the healthcare team with the aim to aid service user’s progression. This demonstrates good practice and a holistic approach when addressing service users needs. The home has a new medication procedure that is to be reviewed in three months time. This review will be monitored and discussed at the next inspection. The staff team are qualified to administer medication according to protocol. Additional and refresher medication training is arranged for the New Year. On examination of selected service user’s medication sheets it was evident that care staff can identify what medication had been given and to whom following the prescription regime. Through training the care staff were able to monitor health conditions of service users and review their medication accordingly. During the inspection there was a discussion around dosage of service user’s medication that is currently being carefully monitored. The aim is to eventually decrease service users medication this is to be conducted under strict guidance and monitoring. This service has the capacity and the ability to go forward with this thinking. The medicines are stored in a locked cabinet that contains separate compartments for internal and external medicines. The home additionally has an audit trail and logs the medication on entry and exit of the home. There is a staff signature sheet that is good practice and forms part of the administration of medication. All medication is doubled checked to minimise errors. An up to date British National Formulary (BNF) was also seen and is placed close by the medication cabinet. The BNF contains information on dosage of medicines and its usage, manufacture and contra indications in which care staff can double check with clinicians. The only shortfall found in this area is in the method of ‘secondary dispensing.’ The home is to review its secondary dispensing method in preparation for service user’s home visits. The term secondary dispensing means the repackaging of medicines into another container with the intention that another individual will administer to the service user at another time. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 17 Reference made by both the Nursing and Midwifery Council (NMC) & the Royal Pharmaceutical Society deem this to be unsafe practice that can potentially cause drug errors. A number of options were discussed during the inspection that would be to liaise with the pharmacist and consider other dispensing alternatives. On the whole the home has a good procedure for providing personal and healthcare which is largely based on choice and consideration of the service users.’ Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good framework is in place to provide assistance to service users’ to express their views. Good systems are in place to ensure that service users are not financially abused and kept safe from neglect. EVIDENCE: The home has had compliments from both relatives and service users’. This was evident in the feedback forms. Service users’ have monthly meetings. The style of the meeting is an ‘informal chat’ in which views are expressed and shared. Each key worker has a one to one with service user if they wish not to attend the meeting. Copies of the service users’ meeting minutes were seen as evidence. Issues for discussion were preparations for Christmas and comments on individual classes and if there was any dissatisfaction with the classes that were being attended. It would also appear that activities enjoyed at the day centre are being continued at the home to which support is being provided to meet that need. The service had a complaint in 2004 which was satisfactorily resolved. This demonstrates that the service is operating a good standard care. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 19 Any compliments are shared with the staff and feedback forms provide positive responses. The organisation has a complaints procedure in a number of formats thus making this widely accessible. The home has a satisfactory system for ensuring that service users’ are safeguarded from financial abuse and neglect. Staff members are trained in the protection of vulnerable adults throughout their period of employment within the organisation. The manager and staff team are aware of the need to consult with the adult protection team if there were any issues arising. The home has a communication passport to assist in the development of communication for service users. Staff spoken with are additionally aware of using the whistle blowing procedure when necessary. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortably decorated to a high environmental standard that exceeds the national minimum standard. EVIDENCE: Orchard Leigh is a purpose built property that accommodates eight individuals with learning disabilities. The home has two self-contained flats, which are independent of the home, the staff are on site for support. Each bedroom has en-suite personalised facilities and far exceeds the national minimum standards. The rooms are comfortably decorated which provide a homely ambience throughout. All rooms including the communal areas were clean and free of any offensive smells. The kitchen/diner has an itemised food board in which service users can choose and plan the following meal. The future ideas are to have theme nights of foodstuff from different parts of the world. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are skilled and caring, with good recruitment procedures in place. Good structures are in place for training that promotes the delivery of a high quality service. EVIDENCE: The Central Registration Team has accepted the acting managers application to become registered manager for Orchard Leigh and the certificate will be the issued in the very near future. The manager has demonstrated a good working relationship with the Commission for Social Care Inspection (CSCI) and has demonstrated proactive qualities within the home over the past year. The staff team are competent and caring and diverse in structure which is supported through training and development. During a discussion with a member of staff it was evident that staff enjoy working at the home and Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 22 appear to work well together. The staff team are open and welcome equalities and diversity and show an understanding of what the concept means. The manager is keen to train staff in this field to enhance the experience of the service users and for the future, taking into account the diverse needs of service users within the home. The manager is described as being “good fun.” The management style is open and inclusive to both service users and staff, delegating tasks when necessary. The homes recruitment procedures protect the service users. Although there are changes to the staff structure the manager is keen to stabilise the staff team. It would appear that a good match between staff and service users is the aim. Service users are given the opportunity to assist with recruitment of new staff members and new potential service users into the home. This is a positive step and shows receptive and flexibility in management style. The home continues to provide a good standard of care and make improvements where necessary. Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well promoting a positive outcome for service users. A self-auditing system needs to be in place to capture any deficiencies with the service. Appropriate systems are in place for maintaining service users and staff members’ health and safety. EVIDENCE: Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 24 The home is well managed by a new manager, who has completed the Registered Managers Award (RMA). The staff have spoken consistently saying that the home was well run and that the manager has a relaxed proactive approach to managing. Other comments were that the manager is open and approachable, effective in their role and cared very much about the service users. Steps are taken to solve any problems arising with service users and their families. This is supported by the service’s willingness to comply with the regulator and work positively with CSCI. The home has an air of calmness that is beneficial for the service users. The quality assurance systems are currently ineffective and the manger will need to devise another system in order to self-audit the home. A requirement will be made on this issue. As a prompt for the manager to put forward an idea on what the intention is likely to be in a way of monitoring the service the home provides. This is to ensure that the home continues to maintain its high standard of quality care, and to address any improvement issues. Although a shortfall was identified the home does provide a good service in which service users’ and relatives are satisfied. One comment from a relative “homely and it does not feel like a care home.” Another comment, “How homely Orchard Leigh is…” The home has a good reporting system and will notify the Commission (CSCI) using the legislative procedures. The manager has polices and procedures in place. Examination of fire records, fire drills and health and safety checks showed regular recording. The manager ensures that all the staff complete their mandatory training such as moving and handling. The manager and team ensure the safe working practices within the home is conducted, and very much a team responsibility. They work together to provide a home that is safe complies with regulation and meets the needs of all the service users.’ Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 3 4 X 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 X 34 3 35 3 36 X 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 (2) Requirement The registered person shall review its secondary dispensing method to ensure that the potential for drug errors is kept to a minimum. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. Timescale for action 22/11/06 2. YA39 24 (1) 22/03/07 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 Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. Extracts may not be used or reproduced without the express permission of CSCI Orchard Leigh DS0000062769.V319844.R01.S.doc Version 5.2 Page 28 - 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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