Inspection on 20/02/07 for Orford House

This inspection was carried out on 20th February 2007.

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 17/10/05

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 Key Unannounced Inspection 20th February 2007 9:00am 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.V330752.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. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orford House Address Meadow Hill Woodcote Park Coulsdon Surrey CR5 2XN 020 8660 2875 020 8645 0762 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.V330752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 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. Orford House is detached property with an internal courtyard and set in secluded well-maintained 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. The weekly fee is £498.00. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection for the year 2006/07. It took place over five hours. Some times were spent looking at the records, talking to some service users and deputy manager. A tour of the building was also carried out. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. The Commission received positive feedback about the care being provided in the home, however a number of negative comments were made with regards to meals at the home. This was discussed with the deputy manager who stated that this issue is being addressed and there was a new chef in post since December 2006. At the time of this inspection an immediate requirement was issued regarding administration of medication. What the service does well: What has improved since the last inspection? A review date has been included on Statement of Purpose and Service User’s Guide .A copy of the most recent inspection report is also included. Service users’ care plans are being reviewed and updated on a regular basis to reflect changing needs and current objectives for health and personal care. Magnetic door holders that respond to the fire warning system now hold the bedroom doors open. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 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.V330752.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users’ needs are being properly assessed, and that the range of needs presented is being appropriately met. EVIDENCE: It was previously required that the service user’s guide must include the most recent inspection report. This is now in place. A review date has also been include on the Statement of Purpose and Service User’s Guide as recommended at the last inspection. Service users are only admitted to the home after a full assessment of their needs has been carried out by the home and the Placing Authority for individuals referred through Care Management, involving the prospective service user/recognised representative. It was noted that the home also carries out a comprehensive needs assessment. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 9 Each service user has a written contract in place that includes the terms and conditions. A contract was sampled and it was noted that it included the room to be occupied by the service user in line with a recommendation made at the last inspection. The home does not offer intermediate care. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are being appropriately met however the system for administration of medication is poor and potentially places service users at risk. EVIDENCE: A sample of care plans were examined and it was evidenced that all aspects of service users’ physical and cognitive needs are being appropriately addressed. There was also evidence from review notes that service users’ care needs are being reviewed on a monthly basis with amendments being made to the service users’ plans where needs have changed. Again this is in line with a requirement made at the last inspection. The deputy manager was able to demonstrate, through individualised healthcare records, that service users are in regular contact with General Practitioners and other health care specialists as required. The home also Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 11 keeps records of all the service users healthcare appointments, in addition to individual daily progress notes. The General Practitioner was visiting the home on the day of the inspection. The medication administration records were audited. There was one instance where prescribed medication had been omitted or administered but not signed for or 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 registered person must ensure that the administration/non-administration of all medication is recorded accurately at all times. 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. An immediate requirement was issued on the day of the inspection regarding this issue. Observation of the staff team interacting with the service users showed that the carers were mindful how they addressed service users, and they were seen to be polite and friendly. Service users are always treated with respect and dignity in accordance with the home’s statement of purpose. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 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. 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 using available evidence including a visit to this service. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are well supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. EVIDENCE: Service users are evidenced as being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and spiritual needs. Staff respect service users wishes regarding daily routines. The home has an activity coordinator in post. Service users are encouraged to maintain contact with friends and relatives and to develop links with the local community. The service users’ comments and observation confirmed that the home is run in a manner that promotes choice and independence. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 13 It was clear from the menus that a wide variety of different food options were available with a lot of consideration given to the nutritional value of the meals provided. The menus offer a choice of meals, and when the published menu options are not desired on the day, alternatives are offered. However some service users have commented that they sometimes have to wait for alternative meals or snacks, as these are not prepared in the home. It is recommended that hot and cold drinks and snacks are made readily available in the home at all times and offered regularly. It is also recommended that a snack meal is offered in the evening and the interval between this and breakfast the following morning should be no more than 12 hours. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 using available evidence including a visit to this service. Complaints are generally managed well, which should ensure that service users’ and relatives’ concerns are listened to. The home’s policies and procedures help protect service users from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. There has been one complaint since the last inspection and Sutton Adult Protection Team carried out the investigation, as there were allegations about the well-being of service users. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission For Social Care Inspection. The London Borough of Sutton’s adult protection procedures were available in the office on request. As mentioned above there has been adult protection concerns raised and this was investigated by the Sutton Adult Protection Team. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally hygienic, clean, homely and comfortable however a number of health and safety issues need to be addressed as these potentially place service users and staff at risk. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedroom are personalised to reflect their individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be comfortable, bright and warm. However the home is not complying with fire regulations and there are a number of health and safety concerns (see standard 38). It was also noted that the baths in two of the bathrooms need replacing. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 16 The home is kept clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. However COSHH materials were left unlocked in the laundry room and this potentially places service users at risk (see standard 42). Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 using available evidence including a visit to this service. Generally staff are recruited appropriately to meet the health and social needs of the service users. However staff training needs and supervisions must be addressed as this could have an impact on the standards of care being provided. EVIDENCE: Copies of the off duty rotas were seen. The home was evidenced to have the numbers and skill mix of staff sufficient to meet service users’ needs. The deputy manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Three staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. There is a staff training and development programme in place. The deputy manager was able to produce documentary evidence of staff attendance of a variety of different training courses that were relevant to the work staff were Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 18 expected to perform, however the registered provider must ensure that all staff are up to date with their mandatory training. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. The health, safety and welfare of service users and staff are not being promoted/protected and this potentially places them at risk. EVIDENCE: In general the registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. However improvement must be carried out with regards to staff supervision and the Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 20 manager must ensure that she keeps herself up to date with her mandatory training. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The deputy manager informed that small amounts of money are kept in separate envelopes for each service user with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. 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. If staff are not supervised on a regular basis this might impact on the care being provided to service users. Failure to comply with the aforementioned requirement represent serious breaches of the Regulations and urgent action must be taken by the registered person to address this to avoid the Commission taking further action to enforce compliance. A number of health and safety issues arose during this inspection and they are as follows: - COSHH materials were left unlocked in the laundry room .The registered provider must ensure that all COSHH materials are kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. - A high number of windows were opening wide on the first floor and there were no restrictors on them. The registered person is required to ensure that all windows have restrictors fitted to stop them from opening wide. - Fire records were also checked and it was identified that on two occasions no fire alarms test had been carried out. The registered provider must ensure that fire alarms test are carried out and recorded on a weekly basis. - The hot water temperatures in some areas which service users have access to were above the recommended level of 43 degrees centigrade. This was discussed with the property manager who stated that he was aware of this issue and this would be resolved within the next two weeks. In the meantime it was agreed that where the hot water is above 43 degrees centigrade, the hot water would be turned off until the blending valves have been replaced. It was also agree with the deputy manager that a risk assessment should be carried out and is in place until such time that this issue has been resolved. This will be monitored by the Commission.The registered person is required to ensure that the hot water temperature is always within recommended level of 43 Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 21 degrees centigrade so that service users and staff are not at risk of being scalded. - One of the fire extinguishers has not been service since 06/04.The registered provider must ensure that all fire extinguishers are maintained at a regular interval that is yearly. - Showerheads in two of the bathrooms could reach the toilet pans and this could contaminate the water supply through backflow. The registered provider must ensure that action is taken to prevent contamination of the water supply in the building. - It was noted that the gas certificate was out of date. The registered provider must ensure that all certificates regarding health and safety are kept up to date and that there is a system in place to monitor this. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 2 X 1 Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the administration/nonadministration of all medication is recorded accurately at all times. (Previous timescale of 31/07/05 and17/10/05 not met). The baths in two of the bathrooms need replacing. The registered provider must ensure that all staff are up to date with their mandatory training. The registered manager must ensure that all staff receives formal documented supervision six times a year. Timescale for action 20/02/07 2 3 OP19 OP30 23(2)(b) 18(1)(c) 20/05/07 20/05/07 4 OP36 18(2) 20/05/07 5 OP38 13(3) The registered provider must 20/02/07 ensure that all COSHH materials are kept locked in accordance to Control of Substances Hazardous to Health Regulations (COSHH) 1999. Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 24 6 OP38 13(4) The registered person is required 09/03/07 to ensure that all windows have restrictors fitted to stop them from opening wide. The registered provider must ensure that fire alarms test are carried out and recorded on a weekly basis. 20/02/07 7 OP38 23(4) 8 OP38 13(4) The registered person is required 13/03/07 to ensure that the hot water temperature is always within recommended level of 43 degrees centigrade so that service users and staff are not at risk of being scalded. The registered provider must ensure that all fire extinguishers are maintained at regular a interval that is yearly. The registered provider must ensure that action is taken to prevent contamination of the water supply in the building. The registered provider must ensure that all certificates regarding health and safety are kept up to date and that there is a system in place to monitor this. 20/02/07 9 OP38 23(4)(c) 10 OP38 13(4) 20/02/07 11 OP38 13(4) 20/02/07 Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 25 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 OP15 Good Practice Recommendations It is recommended that hot and cold drinks and snacks are made readily available in the home at all times and offered regularly. It is also recommended that a snack meal is offered in the evening and the interval between this and breakfast the following morning should be no more than 12 hours. 2 OP15 Orford House DS0000007136.V330752.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V330752.R01.S.doc Version 5.2 Page 27 - 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!