Inspection on 25/10/05 for Orchard Views

This inspection was carried out on 25th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 13/05/05

Orchard Views 17/11/04

Orchard Views 10/08/04

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Snydale Care Home

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The Grove Waltham

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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 White Unannounced Inspection 25 October 2005 09:45 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.V261023.R01.S.doc Version 5.0 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.V261023.R01.S.doc Version 5.0 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 01226284151 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.V261023.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13 May 2005 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 DS0000018270.V261023.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over six and a half hours, from 9.45 to 16.15. Opportunity was taken to make a partial inspection of the premises, inspect a sample of records, observe care practices and talk to residents, staff and the acting manager. The majority of residents and staff were seen and chatted with throughout the inspection. Four members of staff and three residents were spoken to in detail about various aspects of the home. What the service does well: What has improved since the last inspection? What they could do better: A registered manager is urgently required, as the acting manager does not want this responsibility and this was affecting the guidance and leadership available to staff. Staff expressed discontent on this inspection, particularly in regard to staffing levels. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 6 Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. One resident had not been issued with a contract/terms and conditions, omissions and lack of details were noted in the home’s records for example, assessments, care plans, policies and procedures, recruitment, fire records, quality assurance, financial transactions. The storage and procedures for recording and administering medication may place residents at risk. Minor repairs detracted from the refurbishments that had been completed. The health, safety and welfare of both residents’ and staff were not sufficiently promoted and safeguarded as testing of fire equipment and training in fire prevention and/or drills for staff could not be demonstrated and recruitment practices were unsafe. The home was instructed to take immediate action. New employees needed to complete recognised induction training. Current staff need to undertake refresher training in fire safety and first aid. Although all residents expressed satisfaction with the service provided the manager said a formalised quality assurance systems to demonstrate the home was run in the best interest of the residents’ had not been implemented. 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.V261023.R01.S.doc Version 5.0 Page 7 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.V261023.R01.S.doc Version 5.0 Page 8 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): The outcome for standard 2 and 3 were inspected. Standard 6 is not Residents did not have a written contract/statement of terms and conditions with the home. Residents’ needs had been assessed, but the assessments did not provide sufficient detail and were not dated. EVIDENCE: The files for three residents were inspected on a sample basis. One was inspected to determine whether the resident had a contract with the home, they did not. The resident said that they had never been asked to sign a contract. The manager said that this was still being done despite the fact that the resident had lived at the home for over three months. All files contained assessments but it could not be determined when these had been completed because they were not dated. The information of assessed needs did not provide sufficient individual detail. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 9 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): The outcomes for standards 7, 9, 10 and 11 were inspected. Residents had individual care plans but omissions were noted. The system used for the administration of medication and medical records could place residents’ welfare at risk. Residents were treated with respect and dignity. Residents were assured that at the time of death, staff would treat them and their families with care, sensitivity and respect. EVIDENCE: Three residents’ plans of care were inspected on a sample basis. Omissions were noted including regular checks of weight for people who were at risk, no action being taken for residents who had lost weight, no information for residents on special diets, lack of regular reviews for one resident, incomplete and blank risk assessments, GPs not named on medical visits sheets. A member of staff was observed during a medication round. The correct procedure for administration was not being followed which could have placed residents at risk. Medication Administration Records were inspected and various discrepancies were noted including medication not being booked in, handwritten entries not being countersigned, medication trolleys not fastened to the wall when not in use, no double lockable storage for controlled drugs. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 10 Staff were observed respecting residents dignity and privacy. Residents confirmed this. The acting manager was keen to point out that a resident was terminally ill. This information was given to ensure that the inspecting process did not impinge on the resident’s and their relatives’ privacy and dignity. Relatives were in attendance during this time. The manager said that the resident would never be left alone; a member of staff would attend the resident when or if the relatives left. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 11 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): The outcome for standard 15 was inspected. Residents received a wholesome, appealing and balanced diet in pleasant surroundings at times convenient to them. EVIDENCE: The dining room was clean and welcoming. Comments from residents about the meals were positive. These comments included “Plenty of variety”, “Give you what you want”, “Very nice”. Breakfast and tea provided a choice of meal. Lunch was a set meal but residents said that an alternative would be provided if they did not want the meal on offer. One resident said that they were very well fed and added, “I get too much sometimes”. The inspectors dined with the residents. The meal was gammon with pineapple, creamed potatoes, fresh carrots, turnip and cabbage. Gravy was served separately as some residents preferred the meal without. The meal was hot and tasty. Residents had a choice of a hot or cold dessert. Residents on liquidised diets were served and given assistance according to good practice guidelines. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 12 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): The outcomes for standard 16 & 18 were inspected. Residents were confident that their complaints would be listened to and acted upon but the complaints procedure did not include sufficient information for complainants should they wish to make a complaint. Staff had a good understanding of the procedures to be followed should they suspect any abuse at the home, but the home’s procedure did not reflect this. EVIDENCE: The complaint procedure did not contain details as required by the Care Homes Regulations. Residents were confident that any complaints would be dealt with appropriately by the home. The adult protection procedure did not relate to the home or provide sufficient information of the procedure that needed to be taken in the event of an allegation of abuse. The manager said that there were no allegations of abuse. Staff were aware of the action they needed to take if they suspected abuse and could define the types of abuse they would report. Staff were receiving training in Adult Protection. Residents said that they were treated with kindness and had no complaints. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 13 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): The outcomes for 19 & 26 were inspected. On the whole, residents lived in a safe, well-maintained environment, but there were areas of the home that were in need of minor repairs and redecoration. The home was clean and hygienic. EVIDENCE: The home was clean and bright and there were no offensive odours. Since the last inspection new carpets had been fitted in some communal areas and bedrooms. Minor repairs to furniture and equipment had not been carried out since the last inspection and this detracted from the improvements that had been made. All residents spoken with said the home was comfortable and clean. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 14 Some bathrooms and lavatories had marked and stained walls, tiles were missing and toilet seats were worn. One bathroom was out of commission and being used as a storeroom for obsolete equipment, including a broken hoist. The sluice that was broken at the last inspection had not been repaired. The laundry was sited away from residents’ and food preparation areas. The laundry was clean and hygienic. Staff were aware of health and safety and infection control procedures associated with soiled laundry. Infection control procedures were in operation. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 15 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): The outcomes for all the above standards were inspected. Residents’ needs were not fully met by the numbers and skill mix of staff. Residents were not supported and protected by the home’s recruitment procedures. Some staff training was being undertaken to provide them with the knowledge to complete their role in a competent manner, but further training was required. EVIDENCE: The manager admitted that the home was short staffed. This was caused by staff resignations and sickness. The staff employed were working extra shifts in an effort to cover the deficit but rotas indicated that there had not been the full complement of staff on some shifts. Staff expressed their discontent for the number of shifts they were working and that they worked below the full complement on some shifts. Staff shifts commenced at different times but rotas did not reflect the hours worked on each shift. Staff designations were not identified on the rotas and it was not always clear where staff were working i.e. some staff worked as care assistants and as kitchen assistants. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 16 The home were recruiting extra staff but were not following the correct recruitment procedure, which put residents at risk. New employees commenced working on shift without receipt of POVA checks being received or CRB checks being applied for. An immediate requirement was issued. Staff had not received recognised induction training. Discussions with staff identified that they had received some training in moving and handling, first aid, food hygiene and fire safety but some of this was now out of date. Current training on offer included moving and handling and adult protection. Approximately 68 per cent of care staff were trained to at least NVQ Level 2 in care. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 17 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): The outcomes for standards 31, 33, 35, 37 & 38 A registered manager is urgently required, as the acting manager does not want this responsibility and this was affecting the guidance and leadership available to staff. Although all residents expressed satisfaction with the service provided the manager said a formalised quality assurance systems to demonstrate the home was run in the best interest of the residents’ had not been implemented. Written records of financial transactions were maintained, but to safeguard residents financial interests improvements in record keeping are required. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The health, safety and welfare of both residents’ and staff were not sufficiently promoted and safeguarded as testing of fire equipment and training in fire prevention and/or drills for staff could not be demonstrated and recruitment practices were unsafe. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 18 EVIDENCE: The acting manager continued to act as manager although the owners were aware they didn’t want the post. The acting responsible individual said they had advertised the post but had not received any suitable applicants. Staff morale was low. The manager said a formalised quality assurance system had not been implemented but the acting responsible individual was working on this. Regulation 26 visits were now being received by the CSCI but the information did not provide sufficient detail of the acting responsible individuals opinion of the standard of care provided by the home. Residents spoken with expressed satisfaction with the service provided. Residents were enabled to maintain control of their own finances should they wish and had the capacity to do so. Written records were maintained, but two signatures were not recorded when a financial transaction had taken place and financial expenditure was not supported by an appropriate receipting mechanism. The safe facility for storing monies could be moved and therefore was not a safe facility for the safe keeping of monies. The inspector inspected 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. Safety posters were on display. Since the last inspection guards had been fitted to radiators to prevent risks of scalding to residents. When the building was inspected no fire exits were blocked. Fire records continued to need attention. The record stated that weekly testing of the fire alarm system occurred, but there was no record that demonstrated monthly checks of emergency lighting and fire fighting equipment. Fire training and/or drills for staff could not be demonstrated and discussions with staff identified one member would not take appropriate action should the fire alarm sound. An immediate requirement was issued. Measures were in place to ensure the security of the premises and prevent intruders. Also please see outcome for standard 29 re recruitment practices. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 19 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 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X 2 1 Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 20 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 Standard OP2 OP3 Regulation 17 15 Requirement All residents must be issued with a written contract of the home’s terms and conditions. The person completing the assessment must ensure that it is dated. Previous timescale 31.7.05 not met. Care plans must include all information relevant to residents’ needs and the action to be taken to meet the identified needs. Previous timescales of 9 February and 31 July 2005 not met. All risks applicable to the resident in providing their care must be documented in their plan of care. Previous timescale of 31 July 2005 not met. All care plans must be reviewed on a monthly basis. Previous timescale of 31 July 2005 not met. All medication must be appropriately and securely stored. Previous timescale of 31 July 02005 not met. Timescale for action 31/12/05 31/12/05 3 OP7 15 31/12/05 4 OP7 15 31/12/05 5 OP7 15 31/12/05 6 OP9 13 31/12/05 Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 21 7 8 10 OP9 OP9 OP16 13 13 22 11 OP18 13 12 OP19 23 13 OP19 16 & 23 14 OP19 23 15 OP26 23 16 OP27 18 The correct procedure for the administration of medication must be followed. All medication must be booked in, signed and dated as a record of receipt. The complaint procedure must include all the information as required by the Care Home Regulations. Previous timescale of 31 July 2005 not met. The homes policy on adult protection must be updated with information applicable to the home and information that is out of date removed. Previous timescale of 31 July 2005 not met. The bathroom identified with ceiling damage must be redecorated. Previous timescales of 9 February and 30 September 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 all outstanding repairs, redecoration and refurbishment identified together with a timescale when these will be addressed. Previous timescale of 31 July 2005 not met. The broken hoist and obsolete equipment must be removed from the identified bathroom and the bathroom made fit for purpose. The broken sluice must be repaired. Previous timescale of 31 July 2005 not met. Sufficient members of staff must be employed and utilised on each shift to meet the needs of the residents. DS0000018270.V261023.R01.S.doc 31/12/05 31/12/05 31/12/05 31/12/05 30/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Orchard Views Version 5.0 Page 22 17 18 19 OP27 OP29 OP29 17 19 19 20 OP30 13 & 18 21 OP30 18 22 OP31 9 23 OP33 24 24 25 OP35 OP35 16 16 26 27 OP35 OP37 17 17 Rotas must state clearly the designations of staff and hours worked on each shift. All new employees must complete a POVA check prior to commencement on shift. A thorough recruitment procedure, including CRB checks must be completed. Previous timescale of 31 July 05 not met. Suitable arrangements must be in place for the training of staff in first aid. Previous timescale of 30 September 05 not met. All staff must receive induction training within six weeks of appointment. Previous timescale of 6 April 05 not met A manager must be appointed for the home. 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 and 30 September 2005 not met. The safe facility must be made secure. The financial record must provide arrangements for residents and/or their advocate to acknowledge any financial transaction that takes place. A receipting mechanism must support financial transactions. All records required by the regulations and standards must be maintained. 31/12/05 25/10/05 31/12/05 30/12/05 31/12/05 31/12/05 30/09/05 28/02/06 31/12/05 31/12/05 31/12/05 Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 23 28 OP38 23 Documented monthly checks of 28/10/05 fire extinguishers, emergency lighting and fire drills must be maintained. Previous timescale of 31 July 2005 not met. 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 OP9 Good Practice Recommendations That handwritten entries on MAR sheets are countersigned by another member of staff. Orchard Views DS0000018270.V261023.R01.S.doc Version 5.0 Page 24 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.V261023.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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