Inspection on 17/10/06 for Orchard Views

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 25/10/05

Orchard Views 13/05/05

Orchard Views 17/11/04

Orchard Views 10/08/04

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Snydale Care Home

Hawkhills

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Beeches The - North Yorkshire County Council

The Grove Waltham

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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 Mrs Jayne Barnett-Middleton Key Unannounced Inspection 17th October 2006 10:20a X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orchard Views Address 39 Gawber Road Barnsley South Yorkshire S75 2AN 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) 01226 284151 01226 284151 none None Mr Mohammed Sharif Mrs Wendy Sharif Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users may be accommodated at the home age 60 years and above. 25th October 2005 Date of last inspection 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. The fees for the care offered at the home at 17/10/06 are £315 per week. Services not covered by the fee include hairdressing and private chiropody. The homes statement of purpose and service user guide is available in appropriate formats. The homes current inspection reports and complaints procedure are displayed within the entrance of the home. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection conducted by Jayne Barnett-Middleton. Prior to the visit contacts made to The Commission For Social Care Inspection, the homes service history; Regulation 26 visits and a pre-inspection questionnaire were examined. Letter surveys were sent to ten residents and three general practitioners. A fieldwork visit took place from 10.20am until 17.00pm. Opportunity was taken to make a tour of the premises, inspect a sample of records including care plans, training records and staff recruitment files. The inspector spoke informally to most staff and in detail to the four of the staff on duty about their knowledge, skills and experiences of working at the home and to seven of the residents about their views on aspects of living at the home. The inspector wishes to thank the manager, staff and residents for their assistance and time throughout the inspection process. What the service does well: During the visit residents appeared comfortable and were observed to be following their preferred routine. The manager and staff were welcoming and relaxed to talk to the inspector about the service that they provided. The mealtimes observed were relaxed and unhurried. A good and varied choice of menu was offered. Meals were served at two sittings. This ensured that there was enough staff available to serve residents in a timely fashion and provide one to one support for residents who needed assistance to eat. The residents said that they enjoyed their meals and gave positive comments about the meals provided. Residents said that they were satisfied with the care they received and that they were treated with respect and dignity. All residents spoke highly of the staff team describing them as “ very helpful”, “understanding” and “always obliging”. The manager has recently commenced employment at the home. The staff said that staff moral was much improved and that they were benefiting from her support, leadership and direction. Staffing levels were improved and better training opportunities were available. It was evident throughout the visit that the manager had formed good relationships with both residents and staff and that she had worked well towards meeting previous requirements. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Daily records require some improvement, to ensure that the health and wellbeing of the resident can be fully monitored. Nutritional screening is undertaken for residents on their admission but improvements are needed to ensure that, where there is an identified need, the weight of resident can be monitored. Medication records need to detail the current prescribed medication for the resident to fully promote the safety and welfare of residents. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 7 The corridors areas are in need of refurbishment, as the décor looks worn and the carpets stained. The floor coverings in some toilets are in need of replacement. Several seen, whilst clean, were worn and stained. These areas do detract from the overall environment, which in general is well maintained and pleasantly decorated. The sluice that was broken at the last inspection is in need of repair. Staff recruitment files must include, a recent photograph of the employee, the employees’ full employment history and two written references to ensure that the residents are fully protected. Staff are in need of a fire drill, to ensure that they are conversant with the action and procedures to follow in the event of a fire. In general areas seen during the inspection appeared safe and accessible to residents. Turpentine was being stored in a sluice, which was unlocked, potentially compromising the safety of the residents. 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 Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents’ needs and aspirations were assessed and their individual needs reflected in their plan of care. Prospective residents were welcome to visit the home, to help them decide if it was the right place for them to live and to enable the staff to confirm that they were able to meet the residents care needs. EVIDENCE: A full needs assessment was carried out for all residents prior to their admission. Staff from the home also visited prospective residents prior to their admission and an assessment of their needs was completed. This confirmed that the service was appropriate for the resident, and provided staff with the information to formulate an individual plan of care. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 10 Since the last visit residents had been issued with a contract outlining the terms and conditions of living at the home. Two residents, via the survey, said that they had received enough information about the home prior to their admission. One resident commented that they had chosen the home as they had visited the home on a regular basis to visit a friend. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Residents’ assessed needs were reflected in their plan of care. Daily records did require some improvement, to ensure that the health and wellbeing of the resident could be fully monitored. Residents had access to health care services, which met their assessed needs. Nutritional screening was undertaken for residents on their admission but improvements were needed to ensure that, where there was an identified need, the weight of resident could be monitored. In general the procedures in place for the storage, recording and administration of medication was much improved. Two medication administration records sampled did require updating to ensure that it was a current record of the residents prescribed medication. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three care plans were checked which detailed the residents individual physical, social and emotional needs. The format in place included the resident’s life history, psychological health and personal care needs. Where able to residents had been involved in their plan of care enabling them to agree with the staff that it was a true reflection of their care needs. The staff maintained daily records of the care that they had provided to the resident. However, these needed to provide more detail in relation to the residents health and care given. For example one resident was experiencing health problems and had reported that they were feeling unwell that morning. The daily record that had been completed, for the morning shift, was brief and did not comment on their general wellbeing or how their health had been that morning. Risk assessments had been devised which identified the individual risks that were presented to residents for example mobility and falls and the action required by staff to reduce the potential risks to residents, promoting and maintaining their independence. Records of healthcare visits were maintained and demonstrated that residents were receiving regular visits from their general practitioner, chiropodist and optician. Residents said that their healthcare needs were met and described the help that they received commenting, “ I get all the support I need” and “the staff are very understanding”. One resident spoke in detail of how due to a successful cataract operation and the ongoing support of staff they were “ a lot better and I am now relatively independent”. Nutritional screening was undertaken for residents on their admission, which identified any dietary requirements and any eating difficulties, for example swallowing. One care file checked did demonstrate that the resident had lost weight. The manager said that the resident, whilst not on a strict diet, was monitoring their weight. However, this was not reflected in the residents’ nutritional assessment. No record of the residents weight had been made since June 06. Four residents, via the survey said that they usually or always received the support and medical care that they needed. One commented that they were “highly satisfied.” Two general practitioners, via the survey, said that the staff worked in partnership with them and that the staff demonstrated a good understanding of the residents needs. The staff said that they received good support from visiting healthcare professionals in particular the District Nursing team. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 13 Residents were observed to be cared for in a manner that respected their privacy and dignity. Residents seen were clean, appropriately dressed and it was evident that residents who required help to wash and dress had been assisted with this in a manner that respected their dignity. The staff described in detail how they promoted the residents dignity for example knocking on residents bedroom doors prior to entering, addressing the resident by their preferred name and detailing the practices that they carried out when assisting residents with their personal care. Medication was checked on a sample basis. In general medication systems were much improved. Medication received into the home was clearly recorded on the resident’s medication administration record and medication administered had been signed for. Two MAR records seen were not up to date as they still detailed medication that the resident was no longer prescribed. Medication records need to detail the current prescribed medication for the resident to fully promote their safety and welfare. Staff responsible for administering medication was in the process of completing a refresher-training programme to ensure that they were conversant with the procedure for the storage and administration of medication. Medicines including controlled drugs were securely stored and two staff had signed to confirm that the medication had been appropriately administered. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The routines within the home were varied and flexible which met the residents’ individual needs, promoting their choice and independence. The staff at the home was providing some activities for the residents and social activities were planned for residents who wished to participate. Residents were encouraged to maintain contact with their family, friends and the local community as they wished, enabling them to continue to be included in community and family life. The mealtimes observed were relaxed and unhurried. A good choice of menu was offered and special dietary needs were catered for, promoting the resident’s health and wellbeing. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 15 EVIDENCE: During the visit residents were observed to be spending the day as they wished and appeared to be following their preferred routines. Residents spoken to said that the routines within the home were flexible and commented “ I get up as I wish” and “ I can do what I want”. Several residents spoken to said that they preferred to spend the majority of their day in their bedroom as they enjoyed reading, writing and watching television. The staff described how they encouraged residents to make choices about their daily living activities for example when they rose and retired, how they dressed and how they wished to spend their day promoting independence and choice. A programme of activities was in place for residents who wished to take part. Planned events were displayed on the notice board, which included Bingo, a shopping trip and a professional singer. The local church was visiting the home the following day to celebrate Harvest Festival. A Halloween party was planned. The home had been decorated for the event and looked bright and cheerful. Four residents, via the survey, said that there were always or sometimes activities available. The lunch and teatime meal was observed both of which were relaxed and unhurried. Meals were served at two sittings. This ensured that there was enough staff available to serve residents in a timely fashion and provide one to one support for residents who needed assistance to eat. Four residents, via the survey, said that they usually or always liked the food provided. The meals served during the visit looked well presented and appetising. In general residents spoken to during the visit were satisfied with the choice and quality of food offered commenting “its good”, “always plenty” and “ the staff try and give you what you want”. One resident said that they would like their gravy to be served separately. This was passed on to the manager who agreed to deal with the residents’ request. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Residents were confident that their complaints would be listened to and acted upon. The complaints procedure had been reviewed to include sufficient information for complainants should they wish to make a complaint. The home’s adult protection policies and procedures had been reviewed to reflect the action that the staff should take should they suspect any abuse at the home. EVIDENCE: Since the last visit the homes complaints procedure had been reviewed, to clearly describe the procedure for residents should they have any concerns, who would deal their concern and how soon they could expect a response. The manager maintained a log of any complaints made to the home and the action taken to resolve the complaint. Since the last visit no complaints have been made to the Commission For Social Care Inspection or to the home. Four residents, via the survey, said that they knew who to talk to should they be unhappy about any aspect of their care. Residents spoken to during the visit said that they had “no complaints” but were confident that the manager and staff would listen should they have any concerns in relation to their care. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 17 The homes adult protection policy and procedures had been updated to include The Department Of Health guidance ‘No Secrets’ and local Adult Protection procedures. Staff spoken to had a good knowledge of the types of abuse that may occur and were clear of the action that they would take to protect the residents. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The home was clean, comfortable and generally well maintained. Some areas are in need of redecoration and floor coverings in need of replacement to fully promote a well-maintained and clean environment. The premises were clean and free from offensive odours. Systems were in place to promote a hygienic environment and control the risk of infection. EVIDENCE: In general the home was well maintained. The building was clean, free from offensive odours and residents had access to all parts of the home. Since the last visit the lounge carpets had been replaced which presented a pleasant and homely environment. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 19 The corridor areas were in need of refurbishment as the décor looked worn and the carpets stained. The floor coverings in some toilets were in need of replacement. Several seen, whilst clean, were worn and stained. These areas did detract from the overall environment, which was bright and well decorated. Several bedrooms were seen all of which were tidy, appropriately furnished and had been personalised by the resident. In one room the carpet was stained and was in need of a ‘deep clean’. The manager said that she carried out monthly audits of the environment and had commenced a maintenance record to monitor the repairs that were needed in order to keep the home well maintained. Areas seen during the visit were clean and odour free presenting a hygienic environment. The sluice that was broken at the last inspection had not been repaired. Two residents, via the survey, said that home was always fresh and clean. Two commented that the home was usually clean, with one commenting, “ There is room for improvement”. One resident commented that, in their opinion, more domestic staff was needed to maintain a consistent level of cleanliness. The manager said that one domestic was due to commence working at the home subject to satisfactory recruitment checks. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The ratio of staff provided was sufficient to meet the needs of the residents. Minimum staffing levels were being met and staff in general felt that staffing levels had improved. A training programme is available which provides staff with the appropriate training enabling staff to meet the resident’s general and specific needs. 50 of staff held a National Vocational Qualification Level 2 or 3 in care, enabling them to develop their knowledge and promote good care practices. The homes recruitment procedures were improved. However, Some improvements are still required to ensure that the residents are fully protected. EVIDENCE: Rotas checked demonstrated that 4 staff in the morning and afternoon and 3 night staff were being provided. Staff in general said that since the new manager had commenced employment at the home staffing levels were better. The manager said that there was only 1 night care vacancy. Four residents, via the survey, said that there was “usually” staff available if they needed them. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 21 The majority of staff have worked at the home for many years, know the residents well and are able to provide them with a consistent level of care. Residents spoke positively about the service and the support that they received describing the staff as “ very obliging”, “champion” and “ they are always there when you need them”. A training and induction programme was in place. The manager and staff confirmed that new staff did receive support and guidance during their initial weeks of employment. This included fire procedures, reading resident care plans and working with an experienced member of staff until they were confident to work independently. The staff said that they had received a good range of training including moving and handling, adult protection and infection control. Since the last visit refresher training had taken place or was scheduled for first aid and medication. The staff said that better training opportunities were available since the new manager had commenced. Several staff was scheduled to attend palliative care training later in the month. Staff’s training records were incorporated in staff files and planned training was displayed within the main office at the home. The manager was advised to implement a training matrix to detail the training that the staff had received and when refresher training was due. Three staff files were checked. The files seen contained a range of information including their application form, declaration of health and identification but did not contain the employees’ full employment history or a photograph. One file seen, for a member of staff who had worked at the home for two years, did not contain two references. The manager was able to demonstrate that she had identified this shortfall and had requested a reference from the employees’ previous employer. Staff employed had undertaken a P.O.V.A and Criminal Records Bureau check to promote the protection of the residents. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The residents and staff were benefiting from the organisation and leadership of the manager. Forums were in place, which gave residents and staff the opportunity to contribute to the development of the service. Residents’ financial interests were safeguarded by the procedures at the home. In general the homes policies and procedures promoted the health, safety and welfare of residents and staff. The Staff were in need of a fire drill to promote the safety of the residents. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager had commenced employment at the home in June 2006 and is in the process of applying to be registered by the Commission For Social Care Inspection. The manager is a qualified nurse and is currently undertaking a National Vocational Qualification level 4 in Management. Residents spoke highly of the manager commenting, “ The new manager is wonderful”. The staff said that since the new manager had commenced staff moral was much improved and that they were benefiting from her support, leadership and direction. It was evident throughout the visit that the manager had formed good relationships with both residents and staff and that she had worked well towards meeting previous requirements. The manager had recently conducted a residents survey to enable them to comment on the service that was provided and to suggest areas of improvement. Staff meetings were held frequently and the manager said that she did intend to commence resident meetings in the near future. The Registered Provider visits the home on a regular basis to carry out monitoring of the service. Copies of the reports are sent to the C.S.C.I. Arrangements were in place for residents who were unable to manage their monies. Monies were securely stored and records checked evidenced that residents were able to access their monies for hair care and personal items as they wished. The manager had implemented a new system for recording and monitoring resident finances. Receipts were in place and two staff was signing for all transactions, safeguarding resident finances. Information provided prior to the visit demonstrated that all major systems and equipment, including fire equipment, had been routinely serviced to promote a safe environment. In general areas seen during the inspection appeared safe and accessible to residents. Turpentine was being stored in a sluice, which was unlocked, potentially compromising the safety of the residents. Records seen in relation to fire drills did not evidence that all staff had received a fire drill at the required frequency, to ensure that they were conversant with the action and procedures to follow in the event of a fire. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Daily records must be more detailed to ensure that the health and wellbeing of the resident could be fully monitored. Timescale for action 01/01/07 2 OP8 15 Care plans must include all 01/01/07 information relevant to residents’ needs. Nutritional assessments must detail any specific dietary requirements. Where there is an identified need, the weight of the resident must be monitored and the frequency recorded in their plan of care. Medication Administration Records must detail the current prescribed medication for the resident. The corridor carpets must be cleaned or replaced. The corridors must be redecorated. An audit of all toilets at the home must be made. Where the floor coverings are stained and DS0000018270.V312476.R01.S.doc 3 OP8 13,15 01/01/07 4 OP9 13 30/12/06 5 6 7 OP19 OP19 OP19 23 23 23 01/01/07 01/05/07 01/03/07 Orchard Views Version 5.2 Page 26 8 9 OP26 OP26 23 23 worn these must be replaced. The carpet in the identified bedroom must be cleaned. The broken sluice must be repaired. (Previous timescale of 31 July 2005 not met.) Staff files must include: A recent photograph of the employee. The employees full employment history. Any gaps in employment must be accounted for and recorded. Two written references. 30/11/06 01/02/07 10. OP29 19 31/01/07 11 12 OP38 OP38 13 13 All staff must receive fire drills at the required frequency. Hazardous substances must be securely stored. 15/12/06 17/10/06 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. Refer to Standard OP30 Good Practice Recommendations The manager should implement a training matrix to detail the training that the staff had received and when refresher training is due. Orchard Views DS0000018270.V312476.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office 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 DS0000018270.V312476.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. 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!