Inspection on 13/05/05 for Orchard Views

This inspection was carried out on 13th May 2005.

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 Views 10/11/08

Orchard Views 26/11/07

Orchard Views 17/10/06

Orchard Views 25/10/05

Orchard Views 17/11/04

Orchard Views 10/08/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Orchard Views 39 Gawber Road Barnsley South Yorkshire S75 2AN Lead Inspector Jayne White Unannounced 13 May 2005 8:45 th 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Orchard Views Address 39 Gawber Road Barnsley South Yorkshire S75 2AN 01226 284151 01226 284151 None Mr Mohammed Sharif Mrs Wendy Sharif Vacant PC Care Home Only 40 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of OP Old Age (40) registration, with number of places Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17th November 2004 Brief Description of the Service: Orchard Views is a purpose built care home registered for 40 older people. The home is situated on the outskirts of Barnsley town centre within easy reach of local amenities including a main bus route, post office, shops, pubs, clubs, churches and Barnsley District General Hospital. The accommodation and facilities are all ground floor level and there are 38 single and one double bedroom. There is a small car park at the front of the building. The home has a garden area. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over eight and a half hours from 8:45 to 17:15. Opportunity was taken to make a partial tour of the premises, inspect a sample of records, observe care practices and talk to residents, relatives, a visitor, staff and the acting manager. The majority of residents and staff were seen during the inspection and the inspector spoke in more detail to one of the staff on duty about their knowledge, skills and experiences of working at the home, four of the twenty nine residents about their views on aspects of living at the home, one visitor and two relatives. Some standards were not inspected or partially inspected and requirements have been reviewed after further guidance from CSCI. What the service does well: What has improved since the last inspection? Although the supervision of staff was not checked in detail one member of staff said they had received supervision. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 6 What they could do better: The priority for the home is for the owner to consistently carry out required visits himself and to appoint a manager. The assessment completed for residents’ must be dated and signed and all areas identified in the standard assessed to ensure a comprehensive assessment takes place prior to admission. Care was not consistently provided in accordance with the plan and care was provided that had not been assessed for risk. The information on all plans was not provided in sufficient detail. The plans were not signed by the resident and/or their advocate. Records provided to demonstrate the procedures in place for dealing with receipt, recording and administration of medication identified practices that were not safe. Alternatives to the main options at meal times needs to be more varied to ensure the diet for all residents’ is satisfactory. Resident’s food intake needs to be monitored and meals for residents on special diets must be prepared and served appropriately. The complaints procedure did not include sufficient information for complainants should they wish to make a complaint. Staff had received no formal training and the home’s own policy/procedure on adult protection contained information pertaining to another provider and out of date information. All residents spoken to found the home comfortable and clean. Whilst the inspector did not disagree the home was comfortable there were a number of areas that must be improved to provide a better, safer and cleaner environment for residents’ to live. The recruitment procedure was not robust and did not protect the welfare of residents’. Staff were undertaking training, however, practices were not being maintained in the moving and handling of residents and there was not a member of staff trained in first aid on shift. Quality assurance systems that were in place did not demonstrate the home was run in the best interest of the residents’ although all residents and advocates expressed satisfaction or acceptance of the service. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 7 Improvements were required with some of the records kept by the home. Guards or low surface temperatures for radiators were still required together with the actioning of other risks that had been identified, for example, updating the fire role call, monthly testing of fire extinguishers and lighting and accommodating seating arrangements so fire exits are not blocked. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Standard 6 is not applicable. Residents’ had, had their needs assessed, however, the assessment was not dated or signed. The assessment was not very comprehensive. EVIDENCE: The admission process was not as well managed as it could be as the assessment of one resident who had recently been admitted identified all areas in the standard had not been assessed and those that had were not very comprehensive. The assessment was not dated or signed. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 All residents’ had an individual plan of care that identified the resident’s health, personal and social care needs. Care was not consistently provided in accordance with the plan and care was provided that had not been assessed for risk. The information on all plans was not provided in sufficient detail. The plans were not signed by the resident and/or their advocate. A range of health care professionals visited the home to assist in maintaining the health care needs of residents and assistance was sought as appropriate. Records did not demonstrate the procedures for dealing with receipt, recording and administration of medication was safe. Residents felt they were treated with respect and dignity. EVIDENCE: Three residents’ plans of care were inspected. On two of those plans the action to be taken to meet residents needs were identified, however, the daily report and personal hygiene sheet did not demonstrate that care had been provided in accordance with the plan of care. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 11 For the other resident observations of care practice and discussions with the resident identified there was not sufficient detail on the plan to meet the resident’s needs of mobility, diet and the record keeping of their personal possessions. Consistency was not maintained in that all of the plan was not signed by the person drawing up the plan or by the resident and/or their advocate. Care was given that either had not been assessed for risk or had been assessed, but the action to be taken to reduce the risk had not been actioned, for example, moving residents’ in wheelchairs without footplates, no call attachments to buzzers in rooms or radiators that did not have guards or low surface temperatures. All plans were not reviewed on a monthly basis. Residents that were spoken to confirmed that they were satisfied with the care they received. Staff could clearly state what assistance residents’ needed with their personal care and residents said staff offered this appropriately as and when needed. Observations during the inspection together with discussions with resident’s confirmed they had appointments with a range of healthcare professionals. Three residents’ medication records were inspected, one partly self-medicated. Information available for the resident to do this was inadequate as it did not identify the medication self administered, that the risk to self-administer had been assessed and that the resident understood that the medication must be appropriately stored. Discussions with resident’s identified medication they retained was not securely stored. Records were kept of medication received, and administered. There were no gaps in the medication records; however, the medication remaining did not correlate with medication record. The record for administration was confusing as abbreviations were used that according to the member of staff did not correspond to the key identified at the bottom of the record. Entries had been handwritten onto the MAR sheet and were signed by only one member of staff. Medication not to be prescribed to a resident identified in the care plan had not been duplicated on the MAR sheet. The member of staff was unaware of this information. Controlled drugs and medication requiring refrigeration were not being appropriately stored. A controlled drugs register was kept. All residents’ spoken to said that staff were very good, kind and considerate and that their privacy and dignity was observed and their personal care needs were met. Relatives of a resident that were spoken to confirmed this. Staff were able to describe measures they took to protect resident’s privacy and dignity. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 On the whole residents accepted or were satisfied with the lifestyle they experienced in the home and were able to maintain contact with family and friends. The diet for some residents’ was not satisfactory as appropriate alternatives were not offered and specialist diets were served in an inappropriate manner. EVIDENCE: Discussions with residents’ and observations during the inspection identified residents’ were able to maintain contact with family and friends. Discussions with relatives and a visitor identified that visitors were made welcome at any time. Discussions with residents identified they accepted or were satisfied with their lifestyle in the home and the majority had no desire to go out into the community themselves. Observation of residents identified residents’ that were able had varied routines to their day and were given the privacy to follow these. One resident had been able to bring their own bird to the home. The inspector observed carers attempting to colour with residents’ in their lounge chairs and all but one weren’t interested. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 13 The acting manager did say usually after breakfast and lunch the tables in the dining area had different activities, however, this didn’t happen on the day of the visit and residents’ that were spoken to didn’t mention it. Initial impression of the dining room was that it was bright and airy. A large vending machine in the corner detracted from its ambience. The majority of meals were served in the main dining room and were prepared and served by staff at the home. Residents’ who wished to have their meals in other locations were able to do so. The menu for the day was displayed in the dining room. A good choice was offered at the breakfast meal. The food that was served was not always adequate for two residents that were spoken to and appropriate alternatives were not offered. Discussions with the cook and one resident identified alternatives of jacket potatoe and soup were offered. One resident commented ‘there’s only so many times you can eat jacket potatoe and soup’ and ‘sometimes breads not nice – thinks cheap and I’ve always had good food’. One resident did not like the soup that was served and bought their own. The cook demonstrated a good knowledge of the special diets some resident’s needed, however, these were not served in a manner that was attractive and appealing. Residents’ who needed assistance with eating were given this appropriately. The residents’ food intake was not monitored. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints procedure did not include sufficient information for complainants should they wish to make a complaint, however, discussions with residents identified they had no complaints. Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: The home had a complaints procedure. It did not include all the details required by the regulations. Residents’ that were spoken to were not aware of the complaints procedure as such but would complain to the acting manager or a carer if necessary. Not all residents were confident that their complaints would be listened to and dealt with appropriately, however, they had no cause to complain at the moment. The policy/procedure on adult protection given to the inspector was confusing as it identified a different body other than the home being committed to the policy/procedure. In addition an old local multi agency policy/procedure was included even though the home had obtained the current local multi agency policy/procedure. Discussion with a member of staff demonstrated they were confident in reporting any abuse should they become aware of it, however, although they had received information on adult abuse no formal training had been attended. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 All residents spoken to found the home comfortable and clean. Whilst the inspector did not disagree the home was comfortable there were a number of areas that could be improved to provide a better, safer and cleaner environment for residents’ to live. EVIDENCE: All residents spoken to found the home comfortable and clean. Whilst the inspector did not disagree the home was comfortable there were areas that could be improved to provide a better environment for residents’ to live. Some of the carpets at the home were substantially marked and looked dirty and stained. This created a poor first impression of the home, as one of those carpets was the main entrance area which could be a pleasant, inviting and welcoming area. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 16 There were rooms at the home that had suffered water damage and that had stained the décor. In addition, to soak up the water; it appeared a vest and a towel were being used as these had stains on them. They had been left in the area even though there was no evidence of leakage on the day. There were also parts of the home where wallpaper was peeling off the walls or had areas of wallpaper missing. There were a number of minor repairs to furniture that needed addressing and a hoist identified as unfit for purpose that needed removing. More occasional tables were required and those in use either needed re-staining or replacing. Not all bedding in bedroom areas was co-ordinated and this would greatly enhance the aesthetic appearance of the bedroom areas. A cleaning rota was in place and this was found to be unsatisfactory. It identified a room that had been recorded as cleaned the night before the inspection but this room was found to be very unclean and used for inappropriate storage. An offensive odour pervaded the home on one wing. Discussions with a resident on that wing identified the smell was always there but the degree of odour ranged. The smell appeared to come from within the ‘laundry room’. The acting manager confirmed it did and was due to leakage of water in the room. In addition one resident identified problems with drainage of water from sink areas with ‘gunge’ at times appearing. Again the acting manager confirmed this. Laundry facilities were sited in the basement of the home away from food preparation and storage areas. Residents confirmed they were pleased with the laundry service provided by the home and one resident commented ‘laundry lady always comes to work with a smile on her face’. A bath at the home was being used to clean commodes. The manager said this was because a sluice was broken. Liquid soap and paper towels were not available in a number of toilet areas. In addition the toilet paper was left on the floor even in toilets where a toilet roll holder was in place. The majority of extractor fans at the home were clogged with dirt and dust. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 The recruitment procedure was not robust and did not protect the welfare of residents’ who lived at the home. Staff were undertaking training, however, practices were not being maintained in the moving and handling of residents and there was not a member of staff trained in first aid on shift. EVIDENCE: One staff file was inspected. All the required recruitment checks had not been completed to ensure the protection of residents. Wheelchairs used by staff to transfer residents’ were not fitted with footplates, consequently staff were observed throughout the day to move residents’ without footplates. This is an unsafe practice unless this has been part of a risk assessment. There was no evidence of this on the residents’ files. Discussions with care staff identified there was not a person qualified in first aid on shift. Discussions with one member of staff identified they had undertaken a range of appropriate training. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36, 37 & 38 A registered manager is urgently required, as the acting manager does not want this responsibility. Quality assurance systems that were in place did not demonstrate the home was run in the best interest of the residents’ although all residents and advocates expressed satisfaction or acceptance of the service. One member of staff said they received supervision. Improvements were required with some of the records kept by the home. Practices used by care staff together with a check of a sample of records identified the health; safety and welfare of both residents’ and staff were not sufficiently promoted and safeguarded. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 19 EVIDENCE: The acting manager continued to act as manager although they said they didn’t want the post. The owner said he had advertised the post. Aspects of quality assurance were checked including staff and resident meetings. It was apparent that there were areas where the quality of the service was not being maintained, for example, cleaning. There was no evidence that this had been monitored to assess improvements. The recording of resident meetings were inadequate because they did not contain sufficient details to establish whether or not the residents were satisfied with the quality of the service they received. Regulation 26 visits were requested but were not provided. None have been sent to the CSCI since 10 March 2005. Residents spoken to expressed satisfaction or acceptance of the service provided. The acting manager said all staff had, had appraisals and she was now doing supervisions. One member of staff confirmed this. The inspector checked a sample of the records that the home was required to keep. These have been commented upon throughout the report and where necessary requirements made. Records were securely stored. Rooms were centrally heated, however, the radiators continued to have no guards or low surface temperatures. In addition the radiators in the main lounge areas were of a low squat type and were a tripping hazard. Risk assessments had been put in place and the outcome identified guards were to be fitted. This had not been done. Temporary measures to reduce the risk had not been identified. Risks identified by room had been assessed on 19 August 2004. Action to reduce the risk had been identified. A sample of one risk assessment was inspected. Action to reduce all of the risks identified had not been put in place and parts of the assessment had been actioned. Temporary measures to reduce risks until major work could be completed had not been identified. Fire records were not up to date. The record stated that weekly testing of the fire alarm system occurred, however, there was no record that demonstrated monthly checks of emergency lighting. One member of staff was spoken to and they said they had received recent fire safety training. The last record of documented fire drills was 2 July 2004 as was monthly checks of fire extinguishers. The acting manager said this was not the case but no other records could be found. The fire role call was out of date and could put members of the emergency services at risk should a fire occur. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 20 At the time of inspection one fire exit was partially blocked. Window restraints were in situ at windows inspected to prevent falls. Servicing was in place for portable and fixed electrical appliances. Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 1 x 1 x x 3 2 2 Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 3 7 7 Regulation 15 15 15 Requirement The assessment must be dated and signed by the person completing it. Care must be provided in accordance with the plan of care. Further information must be added to residents care plans on their needs and action to be taken by staff to meet their needs. Previous timescale of 9 February 2005 not met. All care plans must be signed by the resident and/or their representative. Previous timescale of 12 January 2005 not met. All risks applicable to the resident in providing their care must be documented in their plan of care. All care plans must be reviewed on a monthly basis. Consistency must be maintained in documenting residents needs in regard to their death, spiritual, religious and social care needs and adding to the plan of care if required. Where abbreviations are used on the MAR sheet they must relate J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Timescale for action 31 July 2005 31 July 2005 31 July 2005 4. 7 15 31 July 2005 5. 7 15 31 July 2005 31 July 2005 31 July 2005 6. 7. 7 7 15 15 8. 9 13 31 July 2005 Page 23 Orchard Views Version 1.20 to the key provided. 9. 10. 11. 9 9 15 13 13 12 & 16 All medication must be appropriately and securely stored. Medication not to be administered to a resident must be recorded on the MAR sheet. A choice of meal must be offered to residents where the main meal on offer does not meet their dietary requirements. Records of food provided for residents must be kept and be in sufficient detail to determine whether the diet is satisfactory and of any special diets prepared for residents. Liquidised diets must be served in an appropriate manner. The complaint procedure must include the twenty eight day timescale. All staff must undertake training in adult protection. Previous timescale of 9 February 2005 not met. The homes own policy on adult protection must be updated with information applicable to the home and information that is out of date removed. The bathroom identified with ceiling damage must be redecorated. Previous timescale of 9 February 2005 not met. An audit of all rooms at the care home must be made by the owner and manager and submitted to the CSCI. It must include an itemised list of any repairs/ redecoration/refurbishment identified together with a timescale when these will be addressed. All areas of the home must be 31 July 2005 31 July 2005 31 July 2005 31 July 2005 12. 15 17 13. 14. 15. 15 16 18 12 & 16 22 13 31 July 2005 31 July 2005 30 September 2005 31 July 2005 16. 18 13 17. 19 23 30 September 2005 31 July 2005 18. 19 16 & 23 19. 26 23 31 July Page 24 Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 kept clean. 20. 21. 22. 23. 24. 25. 26 26 26 26 29 30 16 13 23 13 19 13 & 18 Action must be taken to remove the pervading odours. The practice of cleaning commodes in the bath must cease. The broken sluice must be repaired. Liquid soap and paper towels must be provided in all toilet areas. A thorough recruitment procedure must be completed. All wheelchairs must be fitted with footplates and used when transferring residents unless there is a documented risk assessment not to do so. Suitable arrangements must be in place for the training of staff in first aid. All staff must receive induction training within six weeks of appointment. 2005 31 December 2005 31 July 2005 31 July 2005 31 July 2005 31 July 2005 31 July 2005 26. 27. 30 30 13 & 18 18 28. 31 9 29. 31 9 30. 33 24 31. 33 26 A manager must be appointed for the home. Previous timescale of 9 February 2005 not met. The person left in charge of the home in the absence of a registered manager must demonstrate understanding of their responsibilities. Previous timescale of 9 February 2005 not met. A quality monitoring system must be in place to measure the views of residents and the aims and objectives in the statement of purpose. Previous timescale of 9 February 2005 not met. Regulation 26 visits must be J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc 31 September 2005 6 April 2005 Not checked on this inspection. 30 September 2005 30 September 2005 30 September 2005 31 July Page 25 Orchard Views Version 1.20 32. 33. 37 38 17 13 34. 35. 38 38 13 23 36. 37. 38. 39. 40. 38 38 13 13 carried out in accordance with the regulation. All records required by the regulations and standards must be maintained. Radiators in the home must be guaranteed low surface temperatures or guarded. Previous timescale of 9 February 2005 not met. All risk assessments must be updated and applicable to the person in the room. Documented monthly checks of fire extinguishers, emergency lighting and fire drills must be maintained. The fire roll call must be updated. Fire exits must not be blocked. 2005 31 July 2005 30 September 2005 31 July 2005 31 July 2005 31 July 2005 13 June 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard 3 9 15 15 15 26 Good Practice Recommendations All areas identified in the standard should be covered in the assessment process to ensure residents needs can be met. That handwritten entries on MAR sheets are countersigned by another member of staff. That the main meal of the day offers a choice for residents. That the vending machine is removed from the dining room. The practice of the resident purchasing their own soup must be reviewed. Toilet roll holders should be provided and used where one is in place for the use of toilet paper. J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 26 Orchard Views Orchard Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 Page 27 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Views J51 S18270 Orchard Views V218860 13.05.05 UI Stage 4.doc Version 1.20 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!