Inspection on 13/02/06 for Orford House

This inspection was carried out on 13th February 2006.

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 no outstanding requirements from the previous inspection report, but made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Orford House 29/05/07

Orford House 21/06/06

Orford House 15/08/05

Orford House 15/07/04

Orford House 15/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Orford House Ugley Bishops Stortford Essex CM22 6HP Lead Inspector Sharon Thomas Unannounced Inspection 13th February 2006 09:30 Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Orford House Address Ugley Bishops Stortford Essex CM22 6HP 01279 816165 01279 816858 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.hft.org.uk Home Farm Trust Ms Sandra Forsyth Care Home 26 Category(ies) of Learning disability (26) registration, with number of places Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 26 persons) 15th August 2005 Date of last inspection Brief Description of the Service: Orford House is located in a rural location close to Stanstead Mountfitchet and is registered to provide accommodation for 26 residents with varying degrees of learning disabilities. Accommodation is provided in single rooms at ground and first floor level. The home is located in large accessible, and extensive grounds. All bedrooms in the home are highly personalised. The communal areas are domestic in nature and well used by the residents. Since May 2004 the accommodation in the Orford House site is no longer used and all residents live in the adjacent Dove Cottages. The home aims to provide personal, social and emotional care to the residents living there. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year 2005 – 2006 and took place on 13 February 2006 over a combined time of 12 hours. The lead inspector was accompanied by Ray Finney (Inspector). Fourteen of the fortytwo National Minimum Standards were inspected: two were met, nine were nearly met and three were not met. For the purpose of this report the individual’s living will be referred to as residents. Due to the abilities of the residents it was not possible to gather in-depth information from them therefore the inspectors undertook observations of the residents and staff. The inspectors had the opportunity to speak with the manager, the care manager, and three members of staff on the day. The tour of the premises included observation of three bedrooms, bathrooms and toilets, the communal areas, the kitchens and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The staff verbally reported their commitment to the residents in their care. They were observed occasionally interacting in a positive and caring manner, and the staff were enthusiastic but frustrated regarding their roles in the home. The home is in the process of being extended and the building works were well underway on the day of the visit. This building work has had a negitive effect on some of the service users and this has resulted in the staff being put under increased pressure to deliver effective care. The matter will be discussed further into this report. What the service does well: Relatives and visitors are welcomed into the home and residents felt that the home encouraged their relationships. The home’s Adult Abuse system protects the residents who live there. The manager demonstrated a clear understanding of the areas of improvement required to comply with the National Minimum Standards. The home must be commended for the way it responded to an emergency situation late last year. All of the residents had to be accommodated in a local hotel and their safety and welfare was assured. Staff covered shifts without question, and the service manager ensured that the premises were safe prior to the residents return to Orford House. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The care plans used in the home do not reflect the needs of the residents. The files did not contain basic information regarding the physical, social, mental and emotional needs of the individual. The care plans used in the home did not contain informative, up to date risk assessments. The risk assessments did not provide staff with appropriate information on the issue or the action required to address the issue of risk. The home did not provide residents with an appropriate range of social activities. The care plans did not provide information that directs staff on the social and leisure needs of the residents. The home does provide a service that enables residents to fully integrate with the wider community. The home does not enable residents to participate in the planning of menus, residents are not provided with a daily choice of meals. The care plans used in the home do not reflect the complex healthcare needs of the residents. The home does not have an effective system for the safe administration of medication. The home is not currently providing residents with a safe and clean environment to live in. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 7 The manager at Orford House does not have a clear and effective overview of the management responsibilities under Care Standard Act 2000. The home is not undertaking appropriate Health & Safety checks that ensure the ongoing safety of residents and staff. 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. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected – please see previous report. EVIDENCE: Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 9. Residents’ assessed and changing needs and personal goals were not reflected in individual care plans. Residents health and personal care needs are not well met; individual care plans did not detail the care and support required. The service did not have systems in place to ensure that risk was appropriately identified and addressed. The lack of information in care plans has the potential of placing residents at risk. EVIDENCE: Three residents’ files were examined on the day of the inspection. Two files contained background information but this had not been used to generate care plans that would enable carers to provide appropriate support for residents. The care plans lacked information that identified need, action to address the need, the outcome or long-term aim of the care provided. Overall, information in the files was disorganised, disjointed and incomplete. The care plans did not contain appropriate information regarding the physical, social, mental and emotional needs of the residents. One file examined contained charts for recording weight, visits to the Optician, G.P. and Hospital, but none of these were complete. One file contained a Health Action Plan but this had no information recorded in it. The last recorded risk assessments for one resident Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 11 was dated 20/09/99 and 25/05/00 for another; there were no current risk assessments on any of the care plans examined. Some of the information recorded was either out of date or was not relevant. For example, the file of a resident with impaired vision contained information about the possible adverse effects on vision of a particular anti-convulsant medication. However, this medication had not been prescribed for the service user. There was evidence that Social Services reviews had taken place, however there was no evidence that recommendations made at the reviews had been actioned. The daily recording was poor and did not reflect the care being provided. The concerns regarding the poor quality of the care plans was discussed with the manager and the care manager on the day. The inspectors were concerned that the lack of information in the care plans has the potential of placing residents who have complex needs, at risk. An immediate requirement notice was issued on the day to resolve the situation. The three care plans examined did not contain a general risk assessment. Preadmission risk assessments and general risk assessments documents were found on individual care plans but had such limited information that they could not be used as a working document. The risk assessments are not detailed and did not contain details of the identified risk and the action to address the risk. Many of the residents have complex needs and a comprehensive risk assessment would ensure that residents are protected and supported appropriately. The issue of risk assessments was discussed with the staff and it was evident that staff were not clear regarding the use of risk assessments. This concern was discussed with the manager and care manager and it became clear that the home did not have a system in place to monitor the care plans used in the home. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 17. There was a lack of age, peer and culturally appropriate activities for residents. Overall residents are not enabled to participate in community activities. Overall the residents’ benefit from a well balanced and varied diet. EVIDENCE: Observations by the inspectors indicated that there were few, if any, fulfilling activities taking place in one of the cottages. During the inspection some residents spent 2 – 3 hours sitting around the dining table with no activities or stimulation taking place. Other residents were in the communal living room, the television was on (loud volume) but they were not watching it. Very little interaction was observed between residents and members of staff on duty. During the inspection two residents became distressed and it was observed that the staff did not handle the situation appropriately. One resident’s file examined showed a planner that identified only in-house activities and no activities outside Orford House were planned for, or provided. However, no evidence of the in-house activity recorded in the care plan, was seen on the day of the inspection. Staff spoken with were questioned about the activities available in the home. One member of staff explained that the lack of activity Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 13 was due to it being “half-term”. Therefore no activity had been pre-planned by the home to cover the half term period. The member of staff reported that one resident would be receiving support with an activity on the afternoon of the inspection; the activity in question was to take the resident to the pharmacist to get their prescription. The staff spoken with reported that they were frustrated with the lack of support that they provided in this area, and identified the need for more staffing hours as the main reason behind this issue. The staff spoken with on the day were knowledgeable about the concept of the integration of residents into the community through supporting individuals to use local amenities. Residents are supported to go shopping and get their own prescriptions. There was little evidence that residents use the local library, cinema, church etc. The care plans did not provide evidence that resident’s are supported to integrate into the community. The home has its own mini bus that enables access to local amenities. The home could not provide evidence that residents are involved in the political process. Staff spoken with reported that they felt that residents are not fully supported to undertake activities outside the home as staffing hours are not available to provide this service. Upon discussion with staff it became clear that residents were provided with a well-balanced, nutritional menu. However it was observed that residents were not offered a choice of meals on a daily basis and there was no evidence to suggest that residents were involved in the planning of the menus. The food stocks: fresh, dried and frozen were found in good stock. The standard of hygiene in this particular kitchen was poor and the kitchen was in need of a deep clean. The meal served on the day appeared appetising and well presented; the residents appeared to enjoy their meal and received the appropriate support during the mealtime. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Overall the home provides personal care that promotes privacy and dignity. The resident’s health care needs are not maintained in the home. The residents in the home were not protected by the home’s procedures for dealing with medicines. EVIDENCE: Orford House provides minimal personal care to residents. The issue was not found in any detail in the care plans examined. Two support workers confirmed that assistance with personal care would be provided if required. The care plans examined on the day did not clearly indicate the support and assistance required by the residents for their daily personal care needs. Staff indicated that routines were flexible and took into account the preferences and needs of the individuals living in the home. Observations made on the day confirmed that some positive relationships had been formed and that staff treated the residents in a sensitive and appropriate manner. Staff are patient and report that they are interested in the welfare of the people living there. However it was clear that staff are not provided with the comprehensive information required to ensure that all aspects of care are identified, planned for, and actioned. When speaking with the staff it was evident that they were not aware of some of the necessary information that they would need in order to provide a quality level of care. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 15 Care plans confirmed that residents were registered with a number of local GP’s. All of the current resident group would require support and assistance with their healthcare needs. One care plan indicated that a hospital appointment was cancelled due to staff shortage; there was no evidence to indicate that another appointment had been booked. The support worker on duty confirmed that residents attended the GP service with the support of a member of staff. Care plans did not indicate that the residents accessed a range of health services including: dentists, chiropodists and hospital appointments. Information on health issues was not well documented or recorded. The home has a policy in place on the administration of medication. At the time of the inspection no residents were able to self-medicate. The Medicines Administration Record (MAR) sheets were examined and overall were found to have significant gaps in the information recorded. None of the MAR sheets examined had the section on ‘allergies’ completed. The ‘route’ of medication, e.g. ‘oral’ or ‘topical’, was incomplete for many of the prescribed medicines. Dates and amounts of medicines received from the pharmacy had not been recorded in many cases, so it would not be possible to follow an audit trail to ensure no medication was missing. Prescribed medication had not been identified in residents’ care plan files. Two MAR sheets examined listed PRN or ‘as required’ medication which stated “Take one or two only when required”. However, there were no management strategies in place or guidelines in residents’ records as to the circumstances when this medication should be used. Some medicines had been handwritten on the MAR sheets but contained no date when the medication had commenced, the signature of who had written it or name of doctor who had prescribed it. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home operates appropriate practices and procedures to protect vulnerable adults. The manager and staff actively promote awareness of adult protection issues. EVIDENCE: The home has a clear policy and procedure regarding the Protection of Vulnerable Adults (POVA). The home provides training and support to staff with this issue. On discussion with staff it was clear that they have a clear understanding into the issues around adult abuse. Senior staff spoken with are aware of the POVA procedures, and their responsibilities with regard to ensuring the ongoing protection of the service users in their care. The home has planned for all senior staff are trained in this issue by the end of February 2006. The home had effective guidance systems in place, and worked closely with the local social services department. The manager reported that no allegations of abuse had been made in the home to date. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Overall Orford House is not currently providing residents with a homely, comfortable and safe environment that is suitable to their needs. Residents are not currently provided with a homely, comfortable and safe environment that is clean and hygienic. EVIDENCE: Orford House is undergoing major building works to provide a new service to adults with Learning Disabilities. The new building is situated close to Dove Cottages. On arrival the external area of the home was unsafe, the path leading to Dove Cottages was unpaved and was hazardous to walk on. The staff reported that they were experiencing difficulties on a daily basis in enabling residents to leave the home safely. This issue was discussed with the manager and care manager on the day and an Immediate Requirement Notice was issued to the home to resolve this issue. The grounds had sufficient parking space for both visitors and staff. The interior of the home is in need of re-decoration, and this issue will be addressed when Dove Cottages are refurbished later this year. The bedrooms were decorated and personalised by the residents. The bedrooms were in various states of tidiness, and this reflected the objective of the home in enabling choice and independence for residents. The communal areas in the home were domestic in nature and reflected the tastes of the individuals living there. During the inspection it was Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 18 noted that the living room contained a large number of coat’s and bags and when enquiring it came to light that these belonged to the staff. These were removed upon request, however there was a concern that staff were not aware that this was an issue. Upon inspection of the premises, the inspectors found areas of the homes communal space were not of a satisfactory standard of cleanliness. As previously noted the kitchen cabinets, fridge and work surfaces were in need of a deep clean. The first floor bathroom was not clean or tidy. The home throughout had not been vacuumed; the above issue had been highlighted as a requirement in the previous inspection report and therefore remains outstanding. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Overall the home provided training for staff, however, there was insufficient evidence that training provided met the individual and joint needs of service users. EVIDENCE: On the day of the inspection information about the home’s staff Training and Development programme was not available, so inspectors were unable to get an overview of training provided for staff. Inspectors were informed that basic abuse awareness took place on 18/01/06. Four staff files were examined and evidence was seen of induction training and some statutory training courses. There were letters on file recording dates of courses, although certificates had not yet been copied and placed on file. An advanced abuse awareness course was planned for all senior carers in February 2006. The manager was aware of the training needs of the staff group, but lacked awareness regarding the overall staff training system used in the home. Support staff spoken with were unable to demonstrate a good awareness of the needs of the services users they were supporting. And throughout the course of the inspection staff continuously expressed their concerns regarding the increase in residents needs and the lack of staffing hours required to enable them to address their needs appropriately. Staff were observed occasionally interacting with residents on the day. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 20 Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The home does not currently have a registered manager. The welfare of residents was not always protected by the homes procedures around Health and Safety. EVIDENCE: Orford House has a manager who is in the process of registering with the CSCI. During the course of the inspection it became apparent that the manager might not be fully aware of her responsibilities under the Care Standards Act 2000. The manager was unable to provide the inspectors with relevant information on a number of issues on the day (care plans, training, health & safety). This may be a result of the disjointed management systems within the home. There does not appear to be a clear line of management in the home. The care manager was undertaking the Regulation 26 reports, this issue was discussed on the day and the care manager was made aware that this was the responsibility of the responsible person. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 22 On the day of the inspection some of the emergency lighting inside the home was not working. This issue had been identified in December when it was checked by the contractor, but 2 lights at House 2 and one at House 4 had still not been repaired. There was no external lighting to ensure the safety of the residents. Records examined showed that Health and Safety checks were carried out monthly in residents’ bedrooms. The document used to record the Health & Safety checks contained pictures to make it more ‘service user friendly’. However, there was no recorded evidence that service users actually took part in these Health & Safety checks and there were no signatures on the records to indicate who had carried out the checks. Weekly fire alarm and hot water temperature checks were not up to date. As previously reported the pathway leading to Dove Cottages was dangerous and posed a very real hazard to the residents. Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X X X X 1 X Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 Schedule 3 Timescale for action The registered person must 15/06/06 ensure that all residents have an up to date, accurate and comprehensive care plan. Care plans must indicate the care need, the action to address the need, and the aim of the care. The care plans must reflect all aspects of care and must be directive. Daily records must be detailed and reflect the care provided. The registered person must 15/06/06 ensure that all resident files contain an up to date and relevant risk assessment that can be used as a working document. All aspects of risk must be identified and a management strategy implemented to direct staff on the safe delivery of care. The registered person must 15/06/06 ensure that residents are enabled to integrate fully with the wider community and are provided with a choice of fulfilling and stimulating activity both outside and within the home. DS0000017899.V283712.R01.S.doc Version 5.1 Page 25 Requirement 2. YA9 13(4), 14 (2) 3 YA13YA12 16(2) Orford House 4 YA17 3(3), 16 (2) 5 YA19 15(1)(2) 6 YA20 13(2), 17 7 YA24 16(2) 8 YA30 13(2) 9 YA32 18 (1)(c)(i) 10 YA37 10(3) The registered person must ensure that residents are involved in the planning of the daily meals. The residents must be given a choice of meals and based on their preferences. The registered person must ensure that residents healthcare needs are identified, recorded, acted upon and monitored. The registered person must ensure that the records of the administration of medication are up to date and accurate. Any gaps in recording must be investigated and recorded. The registered person must ensure that service users are protected by the home’s procedures around recording, handling, safekeeping, safe administration and disposal of medicines. Elements of the above are a repeat requirement. The registered person must ensure that the home is safe and that any hazards or risks to residents and staff are identified and addressed. The registered person must ensure that standards of hygiene in the home are improved. Special consideration must be made with regard to the kitchen area to ensure that meals are delivered in a clean environment. The registered person must ensure that all staff are provided with a full range of training. The staff-training programme must be available for inspection at all times. The registered person must ensure that the prospective registered manager is competent and fit for purpose. The manager must be aware of the full range DS0000017899.V283712.R01.S.doc 15/04/06 15/04/06 13/02/06 13/02/06 13/02/06 15/06/06 15/04/06 Orford House Version 5.1 Page 26 11. YA42 26 12. YA42 12, 23(2) 13. YA42 12, 23(2) of responsibilities under the Care Standards Act 2000. The registered person must 15/04/06 ensure that the CSCI receives regular Regulation 26 reports. The responsible individual must complete the Regulation 26 reports. This is a repeat requirement. The registered person must 15/07/04 ensure that the hot water temperatures and fire alarm checks are regularly undertaken and recorded. This is a repeat requirement. The registered person must 13/06/06 ensure that all parts of the home are safe and hazard free. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Orford House DS0000017899.V283712.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Orford House DS0000017899.V283712.R01.S.doc Version 5.1 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. 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