Inspection on 17/10/05 for Orford House

This inspection was carried out on 17th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orford House 10/09/07

Orford House 20/02/07

Orford House 03/05/05

Orford House 21/12/04

Orford House 04/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Orford House Meadow Hill Woodcote Park Coulsdon Surrey CR5 2XN Lead Inspector Mohammad Peerbux Unannounced Inspection 17th October 2005 9:10 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 Orford House DS0000007136.V258742.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. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Orford House Address Meadow Hill Woodcote Park Coulsdon Surrey CR5 2XN 020 8660 2875 020 8645 0762 manager@orford.fote.uk 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) Friends of the Elderly Mrs Susan Eastwood Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Orford House is situated in Coulsdon and owned by Friends of the Elderly, a registered charity. The home is registered to provide care for up to 29 elderly persons. At the time of this inspection there were 27 service users. Orford House is detached property with an internal courtyard and set in secluded wellmaintained grounds, surrounded by paddocks and woods owned by Friends of the Elderly. The grounds are over 45 acres and also accommodate a formal Chinese ornamental garden, an arboretum, lawn areas, flowerbeds and patios. The home is accessed by it’s own and shared private roads that contain speed bumps, and ample parking is provided. Two other Friends of the Elderly homes, Woodcote Grove House and Selkirk Wing, which provides nursing care, are also within the grounds. Accommodation in the home includes bedrooms on the ground and first floor. There is a lift serving all residents floors. The communal facilities include one dining room, one drawing room, an activities/ hairdressing room, an indoor gardening room, kitchenettes for the residents own use, and a chapel. The chapel is attached to Woodcote Grove House. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection for the year 2005/06. It was an unannounced inspection and took place over three and half hours. Some times were spent looking at records, talking to the registered manager, deputy manager and to some of the service users. They are all thanked for their time and assistance. A tour of the building was also carried out. Service users spoken to stated that they were happy with the care being provided. Requirements and recommendations from the previous inspection were also discussed with the registered manager. Overall the inspection confirmed that the home provides a good level of care for the service users who live there. What the service does well: What has improved since the last inspection? There has been discussion through team meeting about staff respecting the privacy and dignity of service users at all times. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 6 Medication training has been extended to all care staff that administers medication. It is positive to see that action has been taken to improve the professional training of staff and that the home is taking more steps to ensure that this continues. What they could do better: 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 DS0000007136.V258742.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 Orford House DS0000007136.V258742.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): 1, 2 and 4 Generally the home provides all of the information needed for potential service users and their relatives to make an informed decision about moving in to the home. EVIDENCE: It was previously required that the service user’s guide must include the most recent inspection report. However it was noted that the service user’s guide contained the inspection report that was dated for the year of 2004. Therefore this requirement will be repeated. A recommendation was also made to have a review date on the Statement of Purpose and Service User’s Guide. Again this has yet to be met and the recommendation will be repeated. Each service user has a written contract in place that includes the terms and conditions however the room to be occupied is not always mentioned. A recommendation was made at the last inspection for Service Users’ contracts to be completed accurately. The manager stated that it is in the process of being done. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 9 The manager advised that service users are in regular contact with other health and social care professionals. The home has good communications with General Medical Practitioners and other community based health professionals who are able to check that assessed needs are being met. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 and 10 Service users’ health, personal and social care needs are not being appropriately met as their care plans are not being reviewed and updated to reflect their changing needs. The systems for administration of medication are poor and potentially place service users at risk. Service users are treated with respect and have their privacy respected. EVIDENCE: There were good examples of care planning documentation. Care records consist of comprehensive assessment tools, full risk assessments, full records of visiting medical professionals, detailed monitoring and medication records, a new simplified, daily care recording pro-forma, and care plans. However it was noted that the care plans have not been reviewed on a regular basis. The registered manager must ensure that service user’s plan are reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 11 The medication administration records were audited. There were several instances where prescribed medication had been omitted or administered but not signed for. While it transpired that there were acceptable explanations for this, these explanations had not been recorded. In all cases where medication is not given as prescribed, staff must ensure that they record the reason for this. The manager must ensure that medication administration records are accurately completed at all times. This was a previous requirement and will be repeated. Failure to comply with the aforementioned requirement represents serious breaches of the Regulations and urgent action must be taken by the registered persons to address this to avoid the Commission taking further action to enforce compliance. The registered manager gave assurance that she would address this issue immediately. It was previously required that the manager must ensure that staff respects the privacy and dignity of service users at all times. This must be discussed and minuted in staff meetings. This has been met. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 12,13,14 and 15 were met at the last inspection and there has been no change; they were not assessed at this inspection. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: Standards 16,17 and 18 were met at the last inspection and there has been no change; they were not assessed at this inspection. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 14 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): 20,21,24 and 26 The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the service users’ health and emotional well being. EVIDENCE: The communal spaces include, one dining room, one drawing room, an activities/ hairdressing room, an indoor gardening room, and six kitchenettes for the service users’ use. The home also shares the chapel with the other two homes on the site, which creates additional communal space. The grounds cover 45 acres and the gardens are well used by the service users. There are 14 toilets in total. Both toilets and bathrooms were accessible, contained aids and adaptations and were lockable for privacy. One of the bathrooms on the ground floor is being turned into a shower room. The work will be starting soon. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 15 As part of the inspection, a tour of the premises was carried out. It was noted that all the bedrooms were decorated to a good standard and have been provided with suitable furniture and fittings in accordance with this standard. It was previously required that the manager must ensure that one of the room which was malodorous during the last inspection, is kept free from offensive odours and should consider an alternative form of floor covering. The manager stated that the carpet in the room is being cleaned on a regular basis and there is plan to change it. The carpet in another room is also being changed. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 16 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): 27,29 and 30 The home has the numbers and skill mix of staff sufficient to meet service users’ needs and ensure their safety. The home’s recruitment procedures protect the service users through vigorous staff vetting. There is a staff training and development programme in place. This ensures that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. The manager advised that the home has recently employed an administrator for fifteen hours per week. There is a procedure for the recruitment of staff. Staff records were examined and were seen to contain references, criminal record checks, original application forms and copies of identification. It was agreed with the registered manager that a copy of the staff criminal record check is kept on their files for inspection. There is a staff training and development programme in place. The manager is very proactive in respect of staff training. All staff is offered a wide variety of training appropriate to the needs of the service users. The manager advised Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 17 that most of the staff have been on medications training. Further training is being organised with regards to care planning. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 35,36 and 38 The health, safety and welfare of service users and staff are not being protected, as fire safety is not being adhered to. Only limited progress has been made with regards to the frequency of staff Supervision. This area therefore remains unsatisfactory. This could affect the quality of the work that the staff do. EVIDENCE: Service users’ personal allowances are kept separately and secure facilities are provided for the storage of this. Records are kept of items handed over for safekeeping. Since the beginning of this year there have been some incidences where service users’ money have gone missing. The Crime Prevention Officer has been contacted and has advised the home accordingly to minimise this Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 19 from happening again. Secure facilities are provided for the safekeeping of money and valuables on behalf of service users. Although recorded supervision has started, the target of six sessions per year has not yet been achieved. The registered manager must ensure that all staff receives formal documented supervision six times a year. This was a requirement from the last inspection and will be repeated. A number of bedroom doors were again wedged open during this inspection and there were no service users in them. The manager must ensure that bedroom doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. This was a requirement from the last inspection and will be repeated. The manager stated that 10 door guards have been ordered and will be installed soon by an external company. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 20 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 2 2 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 2 X 2 Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 5(1)(d) Requirement Timescale for action 31/12/05 2. OP7 15(2)(b) The Service Users Guide must include a copy of the most recent inspection report. (Previous timescale of 31/07/05 not met). The registered manager must 31/12/05 ensure that service user’s plan are reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. The manager must ensure that 17/10/05 medication administration records are accurately completed at all times. (Previous timescale of 31/07/05 not met). The registered manager must 31/12/05 ensure that all staff receives formal documented supervision six times a year. (Previous timescale of 31/07/05 not met). The manager must ensure that 31/12/05 bedroom doors are not wedged open unless held open by a magnetic door holder that responds to the fire warning system. (Previous timescale of 31/07/05 not met). 3. OP9 13(2) 4. OP36 18(2) 5. OP38 23(4)(c) Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP2 Good Practice Recommendations It would be good practice if review date were included on the Statement of Purpose and Service Users Guide. It would be good practice for the Service Users contracts to be completed accurately. Orford House DS0000007136.V258742.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 DS0000007136.V258742.R01.S.doc Version 5.0 Page 24 - 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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