Inspection on 21/06/06 for Orford House

This inspection was carried out on 21st June 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 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 13/02/06

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 21st June 2006 09:30 Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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.V307252.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 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.V307252.R01.S.doc Version 5.2 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 Care Home 26 Category(ies) of Learning disability (26) registration, with number of places Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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) 13th February 2006 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. The accommodation in the Orford House site is about to be used as temporary accommodation while Dove Cottage is being refurbished. The home aims to provide personal, social and emotional care to the residents living there. The fees on the day of inspection ranged from £580 - £2,900 per week. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection key inspection took place on 21 June 2006 and was carried out by two inspectors over 14 hours. Twenty of the forty-two National Minimum Standards were inspected: eleven were met, eight were nearly met and one was unmet. For the purpose of this report the individual’s living in Orford House will be called residents. The inspection process included: discussion with the three members of staff on duty, and three residents. The tour of the premises included observation all of the bathrooms and toilets, all of the communal areas, the kitchens and the laundry. There was also an opportunity to visit the new Orford House building where some of the existing service users will be moving in July 2006. There was an opportunity to spend a considerable period of time observing the care being provided by the member of 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 home has had a number of additional visits due to concerns regarding the standard of care being provided in the home. The management and staff in the home have been committed to improving the issues that had been identified and have been developing the areas to ensure a better quality of care for the residents. The support workers on duty were observed interacting in a positive and caring manner, and the support workers were enthusiastic regarding their role in the home. The manager was fully available on the day of the visit. The home was warm, clean and tidy and now provides a pleasant and caring environment for the residents to live in. What the service does well: The home is working well in providing a service that is based on promoting independence and the care is centred around the client. Part of the aim of the home is to enable residents to become independent with a view to living permanently in the community if possible. The residents living in Orford House benefit from an established, and knowledgeable staff group who give sensitive, and professional care. The staff have a well-formed knowledge regarding the needs of the individual residents. This was seen in the positive relationships that had formed between the residents and staff. The routines in the home are as flexible as possible and are changed to the meet the varying needs of the residents. Relatives and visitors are welcomed Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 6 into the home and residents felt that the home encouraged their relationships. Some of the activities provided were specifically designed to provide stimulation for residents with a learning disability. What has improved since the last inspection? What they could do better: The home’s care plans did not contain sufficient or updated information regarding the care and support that was required. The home does not provide evidence that service users and or relatives are involved in the care planning process. Care plans do not contain adequate risk assessments required to reduce or manage the risk experienced by residents. The residents are not provided with a full programme of social activity, residents are not fully involved in planning the menu and the home offers little choice to residents with regard to the food that they eat. Records examined confirmed that the agency is not providing training for all staff, on the issue of the Protection of Vulnerable Adults (POVA) The issues identified above are important as the lack of sufficient information in care plans could ultimately impact on the quality and standard of care that service users receive. The lack of training may impact on the competence of staff, and therefore the protection of service users. The lack of choice over the menu may result in the lack of independence for residents and an infringement of their rights. This report contains eleven requirements linked to the above issues and may be found at the end of this report. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 7 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.V307252.R01.S.doc Version 5.2 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.V307252.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a thorough pre-admission system in operation that ensures that the needs of prospective residents are fully assessed and can be met. EVIDENCE: Orford House has not had any new admissions since the previous inspection. The manager confirmed that an external consultant completes the initial assessment then discusses the outcome with the management. The homes resident care plans sampled contained appropriate pre-admission assessments. The home’s pre-admission document is being developed and will be used as a document that will generate the care plan and the new system will be eventually be computerised. The home’s admission procedure included the involvement of relevant professional agencies, and offered the prospective resident/relatives an opportunity to visit and stay at the home prior to admission. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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, 7, & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are well met; overall individual care plans did not detail the care and support required. Residents are enabled to make informed choices regarding their care and are supported to take risks both in the home and outside the home. EVIDENCE: The resident care plans have been developed over the past three months and are being developed to meet the National Minimum Standards. The care plans now contain increased detail but still do not provide clear guidelines to staff as to how to deliver the necessary care. The care plans do not contain the issue action and aim of the care provided. The care plans did not contain information when a change in need had occurred. The four care plans sampled indicated that these are not reviewed on a regular basis and that residents are not involved in the care plan and review process. The daily records of care plans are detailed and well maintained. The CSCI and the management of the home have had a great deal of discussion regarding the quality of care plans and Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 11 related documentation. Two of the current fourteen resident care plans have been developed and were examined on the day. These care plans were comprehensive and concise and the manager and staff were commended for the good piece of work, however the manager was requested to develop the other twelve resident care plans as soon as possible. From discussion with staff and observation of care practices in the home, it was evident that the residents in the home are enabled and supported to make decisions and choices regarding their lives. These issues are recorded in some of the care plans. Records seen indicated that the home provides the residents with some opportunities and experiences that support their independence. Care plans recorded aspects of care that reflected infringements on the rights of the individual. Staff confirmed that residents are in control of their daily lives and one stated, “My job is to support the residents to make decisions about their lives”. The staff spoken with confirmed that they were not always provided with information regarding risk when they were initially provided with resident care plans. General risk assessments were found on individual care plans but were not sufficient to guarantee the safety of residents. Residents are unable to leave the home without being escorted by a member of staff and they also enabled residents to undertake household tasks with support. The home’s aim and objective is to promote independence, and risk taking is central to the service. However, this aspect of care is not well planned and hazards are not always identified and addressed. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in a range of age, peer and culturally related activities and are part of the local community. Residents are encouraged to maintain and develop personal relationships and their rights are respected and individual responsibilities identified. Overall meals are not varied, balanced or appropriately presented and do not offer residents a choice. EVIDENCE: The complex needs and learning disabilities of the residents living in Orford House mean they are unable to participate in paid employment. However, service users are supported to take part in a programme of activities and to access the local community. The daily logs in two resident files were examined and show that activities such as pottery and communication with picture cards take place within Orford House. During term time, college activities such as Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 13 communication through dance and drama and woodwork take place. A member of staff spoken with said when college closes for the holidays, a different summer programme takes place. Records show residents have trips out for fishing and some go to the Thursday Gateway Club run by Mencap. On the day of the inspection visit residents were doing jigsaws, and playing card games with members of staff. Staff spoken with say that residents enjoy trips out, particularly when the weather is good. It was felt that the residents would benefit from the home reviewing its provision of activity and reassess the needs of individual residents around this issue. From observations on the day it was clear that the home has flexible routines that were developed to support residents. Mealtimes are as flexible as is possible, and individual rooms could be cleaned when the resident chose to do so. One resident was observed leaving the home with a member of staff and this resident stated that they felt that the home did not impose any restrictions on their freedom of movement stating, “I go out when I want to”. From discussion with the support workers it was clear that the home promotes independence. Staff and visitors have to request permission to enter both bedrooms and communal areas. Residents’ mail is not opened by staff but opened by the resident if possible and read by staff if necessary. The support workers were observed interacting with the residents and it was clear that residents are central to the care service that is provided. Staff spoken with said that there has been some informal consultation with service users to find out what foods people like and dislike. One service user’s care plan examined shows a pictorial record of preferences around food. However, there is no evidence that Service users are being asked what they want to eat; on the day of the inspection visit no menus were available in either cottage 2 or cottage 4. The lunchtime meal in both cottages consisted entirely of processed foods such as pizza, sausages, tinned spaghetti and potato ‘wedges’. There was no alternative available in either cottage. In one cottage a member of staff said that they had asked some of the service users if they would like pizza and pasta so that is what was prepared for all service users. Food stocks examined consisted mainly of tinned foods, pasta, frozen vegetables and fish fingers, although some fresh fruit was available in cottage two. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident’s physical, mental, and emotional health care needs are met in the home. The home provides personal care in a safe environment and meets the physical and healthcare needs of the residents. Overall service users are protected by the home’s policies and procedures for dealing with medicines, although some improvements are needed both in the storage of medication and the training of staff. EVIDENCE: Overall the residents health care needs are recorded in individual care plans. Residents are supported to take decisions regarding their health care needs and these decisions are recorded in individual daily records. However, the care plans are being developed to provide more comprehensive and concise healthcare information for staff. Resident’s health issues are monitored and reviewed and any changes in health would be reported to the GP and/or District nurse team. The home has strong links with the local primary health care team. The home provides minimal personal care to residents. The issue was found in some detail in the care plans examined. The support workers spoken with Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 15 confirmed that assistance with personal care would be provided if required. The care plans examined on the day gave some indication of the support and assistance required by the residents for their daily care. 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 positive relationships had been formed, and that staff treated the residents in a sensitive and appropriate manner. Staff are patient and appeared genuinely interested in the welfare of the people living there. The home operates a monitored dose system and there are no residents who are self-medicating currently living in the home. There is an appropriate medication policy in place. Medicine Administration Record (MAR) sheets examined are accurate and well maintained. Overall there is an audit trail that can be followed on the MAR sheets, recording quantities and dates of medications delivered, although this was not completed consistently on all MAR sheets. Training around medication is carried out ‘in-house’. One member of staff spoken with is aware of correct procedures around administering medication. The manager has had discussions with the providers around reviewing training, although no changes have yet been made. The manager showed an awareness of appropriate procedures around controlled drugs. Since the last inspection visit, protocols around the administration of PRN (as required) medication have been produced. Resident records examined indicate that medication is recorded in a Health Action Plan. Guidelines around the administration of medication in one file examined had been reviewed recently and gave comprehensive information and instructions to staff. There is one large lockable cabinet for the storage of medication; however, this does not provide enough space to enable topical and oral medications to be stored separately. The manager provided evidence that she has asked for a shelf to be put in each cabinet for the separate storage of internal and external medications and has requested that the providers order two new medicine cabinets. The home does not have a lockable fridge for the storage of medication such as eye drops that need to be kept below a certain temperature. One open bottle of eye drops stored in the medicine cupboard contained instructions to discard unused solution after 28 days, but the date of opening was not marked on the container. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 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): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an effective complaint system that enables residents to make complaints. Overall residents are protected by the home’s policies and procedures around abuse issues, although improvements to practices are needed to ensure staff are more alert to potentially abusive situations. EVIDENCE: The complaints policy was prominently displayed in the foyer of the home. The content of the policy met the National Minimum Standard. The complaint procedure has been developed into an alternative format (pictorial) that was understandable to the residents. A record of complaints received, was maintained. The record indicated the issue, action taken and outcome of the complaint. New complaints received that had been received since the last inspection were dealt with appropriately. Staff spoken with confirmed that residents are encouraged to make complaints and the staff were aware of the procedure that is run by the home. As a result of a recent PoVA alert, the Team Leader attended a strategy meeting and informed the inspector that the home received input from the local Learning Disabilities Community nursing team as a result of the strategy meeting. However, the manager was not involved in this process and documentation around the outcome has not yet been received from the local authority. The Team Leader was also able to inform the inspector how the inappropriate behaviour of the maintenance man that had been observed at Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 17 the previous inspection was dealt with. The Team Leader contacted the manager of the company providing the maintenance staff and that particular employee would not be retuning to the home. At the time of the incident staff did not appear to notice either the behaviour of the workman or the effect on residents. Although the home has policies in place and staff have received training around Protection of Vulnerable Adults, practices have the potential of not protecting residents. The manager must ensure that communication is improved between staff and the management team and within the management team itself so that issues affecting residents are identified and dealt with appropriately. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall residents live in a homely, comfortable and safe environment that is clean and hygienic. EVIDENCE: The Fire Log book examined shows that weekly checks are carried out on the fire system and emergency lighting. Staff records examined showed that fire training was provided in March 2006 by means of a video entitled “Fire Drills and Evacuations”. Records examined show that water temperatures are checked fortnightly. Residents would receive greater protection if staff checked water temperatures more frequently. Records examined show that Team Leaders carry out Health & Safety checks either weekly or fortnightly. There is also documentation in place to record Health & Safety checks in service users rooms, although records examined show these are not carried out on a regular basis. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 19 The home is located in a quiet in area in Ugley and is in keeping with the surrounding property. The home has access to the local town centre through the local bus service, and has it’s own transport (mini-bus) to access the community. On arrival the external area of the home was secure, clean and free from hazards. There have been issues regarding the safety of access for residents and the home was required to pave the footpath to Dove Cottages, this issue was addressed by the June 2006 inspection. The communal areas of the home are not well decorated and appear somewhat institutional in nature. The residents bedrooms are well decorated and furnished, the rooms had been personalised with the assistance of relatives and staff. Overall the home is now warm, bright and airy but would benefit from investment in redecoration. The Dove Cottages are about to be re-furbished to a high standard and the works are due to commence in July 2006 and finish in early 2007. The standard of hygiene has improved and there were no offensive odours. The home has a yearly maintenance programme and the manager is able to influence the budget plan as needed. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 20 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, 34, & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are not provided with comprehensive training that enables them to meet the needs of the residents currently living in the home. Overall the home provides residents with a knowledgeable staff team. The recruitment procedure in the home was not robust and therefore did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The three staff personnel files examined did not contain all of the information necessary to ensure the safety of residents through the recruitment process. None of the three files contained a photograph. All of the files contained a Criminal Reference Bureau clearance check; the manager confirmed that these are held in the administration office, the inspector had the opportunity to review all of the CRB certificates. The manager was advised that all future original CRB checks must be held and made available in the home until they have been examined by the inspector. The manager was reminded that staff must not commence employment until all of the required documentation was in place. There is a requirement made regarding this issue and this may be found below. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 21 From discussion with the staff and the residents it was evident that the staff are supported to do their jobs. The staff have a clear understanding of the issues and needs of the residents. The staff are aware of their responsibility of care that aims to provide choice and increase independence. Four of the eighteen care staff in the home has achieved the NVQ Level 2; the home is not set to reach this standard by the agreed date. Staff receive key training in the home that includes first aid, fire training, food hygiene and manual handling. Additional training includes: protection of vulnerable adults, medication training, and COSHH training. The home provides an induction and foundation programme that meets the (TOPPS) specification. Records are available that indicate the programme of training provided in the home. However the staff files indicated that staff are not provided with a full range of appropriate training opportunities. One member of staff stated that they had not received fire training and felt that not enough training relevant to learning disabilities. Staff spoken with stated that the training provided in the home is “suitable to my role” and “is completely relevant to the residents”. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 22 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, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a competent, skilled and experienced manager. The home does not have a well-maintained quality assurance programme. Overall the safety of residents and staff is promoted and protected by the home. EVIDENCE: Since the last inspection visit, the manager is in the late stages of being registered with the Commission for Social Care Inspection. Discussions with the manager show that she has a good awareness of National Minimum Standards and Regulations. The manager holds the D32/D33 NVQ Assessor’s award and is in the process of doing the Registered Manager’s Award, having completed two units. On completion of the RMA, the manager told inspectors that she intends to enrol for an NVQ level 4 in Care. The manager has worked Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 23 with Home Farm Trust (HFT) for 6 years and has completed all HFT’s mandatory training. The manager has had in-house training relevant to the management role and has completed Supervision training, Recruitment training, Dealing with Poor Performance and Investigation Skills. The home has not implemented an effective quality assurance, the manager confirmed that she will speak to the management team and get the programme implemented. The manager confirmed that she would notify the CSCI when the programme is implemented and will send the results of the programme when analysed. Evidence provided shows that required maintenance and associated records are being kept. Records examined show that there is a fire logbook and emergency lighting is checked weekly. Staff received in-house fire training in March 2006, using a video called “Fire Drills and Evacuations”. Other records examined show that checks on water temperatures are carried out fortnightly. More frequent checks are necessary if service users are to be protected from risks of scalding. Electrical appliances have also been checked (PAT testing). Records examined show that Team Managers carry out Health & Safety checks; some records show these being done weekly, others approximately fortnightly. There is a form for carrying out Health and Safety checks on residents’ bedrooms; this is in an easy to read format with clipart images to make it user friendly for service users with learning disabilities. However, records examined show that these checks are not being carried out regularly. A sample of two staff files examined show that staff receive training around Health & Safety, Control of Substances Hazardous to Health (COSHH), Manual Handling and Basic Food Hygiene. Two groups of staff are doing a distance learning course on Infection Control. Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 1 X X 2 X Orford House DS0000017899.V307252.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 Schedule 3 Timescale for action The registered person must 31/10/06 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. This is a repeat requirement. The registered person must 31/10/06 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. This is a repeat requirement. The registered person must 31/10/06 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 DS0000017899.V307252.R01.S.doc Version 5.2 Page 26 Requirement 2. YA9 13(4), 14 (2 3. YA12 16(2) Orford House 4. YA17 3(3), 16 (2) 5. YA19 15(1)(2) 6. YA32 18 (1)(c)(i) 7. YA35 18 (1) (c) 8. YA23 18 (1) (a) 9. YA39 17 (1) 10. YA42 26 11. YA42 12, 23(2) home. This is a repeat requirement. 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. This is a repeat requirement. The registered person must ensure that residents healthcare needs are identified, recorded, acted upon and monitored. This is a repeat requirement. The registered person must ensure that all safety checks and information is gathered prior to the employment of any new member of staff. This is a repeat requirement. The registered person must ensure that all staff are provided with a full range of training and that evidence of this is well maintained on individual staff files. The registered person must ensure that information regarding POVA issues is well documented and distributed to the necessary members of staff. The registered person must ensure that a quality assurance system is created; the information analysed, acted upon and reported to the CSCI. The registered person must 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 ensure that the hot water temperatures are regularly undertaken and recorded. This is a repeat requirement. DS0000017899.V307252.R01.S.doc 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/10/06 31/08/06 Orford House Version 5.2 Page 27 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.V307252.R01.S.doc Version 5.2 Page 28 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.V307252.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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