Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 08/06/05 for Orione House

Also see our care home review for Orione House for more information

This inspection was carried out on 8th June 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home has a relaxed and friendly atmosphere and good care is provided to the service users, staff were observed to have a very good rapport with service users at the time of the inspection. The staff were seen to be caring and conscientious and service users choice was respected. There is a strong emphasis on providing good spiritual care at this home.The large garden is beautifully maintained and is an asset to the home; it also contains a chapel for the use of service users, relatives and staff. The conservatory is attractive and clean. The manager is competent and experienced and provides good support for the staff.

What has improved since the last inspection?

Both the Statement of Purpose and Service Users Guide have been updated and are comprehensive and well presented. The standards of hygiene and cleanliness have much improved since the last inspection and the home was found to be clean and comfortable on the day of inspection. Improvements within the staffing structure now mean that the Manager is free to manage the home and to ensure administrative duties are completed. It also enables her to ensure staff supervision and training are taking place. The acquisition of a computer has also helped the Manager to update many records and carry out her role more effectively. Immediate requirements issued at the last inspection in respect of window restrictors and a chair requiring disposal have now been met. Window restrictors are now in place at the home and the chair has been discarded. There is a designated activities co-ordinator in place at the home and this enables service users to have a wider choice of activities. The home is acquiring a minibus to ensure service users have more access to outside activities.

What the care home could do better:

Care plans still require attention to ensure they are regularly reviewed and information is archived, although the inspectors recognise this is being addressed and improvements have been made. The Pharmacy Inspector discovered some shortfalls around the area of medication and Requirements have been set as a result. The home must also ensure that all Requirements relating to health and safety (Standard 38) such as those relating to the fire doors being wedged open and hot water temperatures are addressed.

CARE HOMES FOR OLDER PEOPLE Orione House 12-14 Station Road Hampton Wick Kingston-upon-Thames KT1 4HG Lead Inspector Sharon Newman Unannounced 8 June 2005 10:00 am th 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 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. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Orione House Address 12-14 Station Road Hampton Wick Kingston-upon-Thames KT1 4HG 020 8977 0754 02089770105 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Sons of Divine Providence Ms Ursula Harrison CRH Care Home 34 Category(ies) of OP Old Age (34) registration, with number DE (E) Demetia - Over 65 of places MD (E) Mental Disorder - Over 65 Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th February 2005 Brief Description of the Service: Orione House is a purpose-built care home owned by the Sons of Divine Providence. They are a Catholic Missionary Order of Priests, Nuns and Brothers who welcome all faiths to their Homes. Personal care care is provided for thirty four service users. Accommodation is provided in single rooms. The home is situated in a residential area close to Hampton Wick Station and local shops. There is a large conservatory to the front of the home which leads to a garden and carpark. At the rear of the house is an enclosed garden with flower beds, mature trees and a pond. A chapel is situated in the garden which is for use by all service users at Orione House. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspection Team: Sharon Newman Sandy Patrick Jeremy Howe Regulation Inspector Regulation Inspector Pharmacy Inspector Two Regulation Inspectors conducted this inspection over one day on 8th June 2005. The Pharmacy inspector conducted a separate inspection on 14th June 2005 and his findings are included in this report. The Registered Manager was present throughout the inspection and staff, service users and their relatives were also spoken to. Records examined included care planning documentation, health and safety information, and staff files. A tour was taken of the premises. The Manager and staff were friendly, open and professional and the inspectors were made welcome by all. There have been a considerable number of improvements made at this home since the last inspection visit and it is evident that staff have worked hard to improve upon many areas within the home. The Inspection team congratulates the Manager for her hard work to continue to raise standards at this home. Nearly all the Requirements set in the previous inspection report have been met. Feedback at this inspection visit from service users and relatives was very positive. One visitor said ‘This home is lovely’ another stated that they were able to spend as much time at the home as they wanted when visiting their family member. One service user said that ‘the staff are very kind’ and the ‘food is good’. Another stated the ‘food is excellent and the chef is very good’. One service user commented ‘it is just like home here’. What the service does well: This home has a relaxed and friendly atmosphere and good care is provided to the service users, staff were observed to have a very good rapport with service users at the time of the inspection. The staff were seen to be caring and conscientious and service users choice was respected. There is a strong emphasis on providing good spiritual care at this home. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 6 The large garden is beautifully maintained and is an asset to the home; it also contains a chapel for the use of service users, relatives and staff. The conservatory is attractive and clean. The manager is competent and experienced and provides good support for the staff. What has improved since the last inspection? What they could do better: Care plans still require attention to ensure they are regularly reviewed and information is archived, although the inspectors recognise this is being addressed and improvements have been made. The Pharmacy Inspector discovered some shortfalls around the area of medication and Requirements have been set as a result. The home must also ensure that all Requirements relating to health and safety (Standard 38) such as those relating to the fire doors being wedged open and hot water temperatures are addressed. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 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. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 9 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 standard(s) 1, 2, 3, 4, 5 Service users are provided with comprehensive information about the home to enable them to make decisions about their care. There are appropriate procedures for the assessment and admission of service users. Assessments are thorough and this attention to detail ensures service user needs are met. EVIDENCE: A Service User Guide is in place in the home it is presented in an organised folder and contains a location map and information about the Sons of Divine Providence. Other information contained within this documentation includes: the philosophy of care, a standard contract, a Statement of Purpose and the complaints procedure. The Statement of Purpose contains information about: the home’s aims and objectives, facilities and services, staffing, admission criteria and social activities. There is good information for service users displayed on notice boards around the home including the complaints procedure and the last inspection report. Contracts were in place for service users whose files were examined. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 10 Full assessments are carried out by the Manager prior to a prospective service user being admitted, and they are invited to visit the home or undertake a trial stay prior to choosing to live at the home. The Manager said that all the service users have recently been reassessed by social services. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7, 8, 9, 10, 11. Although ongoing work is still needed in the areas of care planning it is recognised that there has been an improvement in the recording of information in the care plans. The health needs of service users are well met with evidence of good multi-disciplinary working taking place. On the day of the Pharmacy Inspectors visit errors in medication recording were found that might have an affect on the welfare of service users. Personal support in this home is offered in such a way as to promote and protect service users privacy and dignity. EVIDENCE: Four service user care plans were examined at this inspection visit and were found to be thorough and comprehensive in content. They contained photographs, personal details and information about activities of daily living. Improvements have been made in care planning however, some shortfalls were noted. Not all care plans were found to have been reviewed monthly and some risk assessments require archiving as out-of-date risk assessments were found to be filed with more up-to-date risk assessments. The daily care notes need to contain more detail to demonstrate that the needs outlined in the care plans are being met. Evidence was seen in care plans of input from health care professionals including: GP’s, chiropodists and dentists. The Manager stated that a Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 12 chiropodist, dentist or optician will visit the home if service users require those services. Service users were seen to attend appointments at local hospitals accompanied by staff members. The written medication policies and procedures were not reviewed on this visit. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. The person in charge was interviewed and all medication not supplied in the monitored dosage system was counted and compared with the record of receipt and administration. From these observations and discussions one service user had been recorded as receiving an item of medication once a day when the dose written on the administration record indicated it to be given four times a day. The doctor had changed the dose to once a day but this had not been reflected on the administration record. One service user had been recorded as receiving the incorrect strength of medication following a change in dose. One service use had not had the administration of their night time dose of cream recorded. In two instances large amounts of medication had been returned. It was not clear from the records why such large amounts had been returned. The amount of medication agreed with the amount that should be in stock for all instances except for one service user. From discussion with the person in charge it appeared that the receipt of medication had been recorded inaccurately. Eye preparations were not dated when opened. A new supply is obtained every month ensuring that these items are changed before the expiry period is reached. One service user did not have their current treatment card for their Warfarin prescription. All other records had been completed accurately and provided evidence that all medication had been administered correctly, medication was stored and administered safely. Only appropriately trained and designated staff administer medication. The home has arrangements for the ordering, storage, recording and auditing of medication and has access to a pharmacist for advice. There is a telephone booth situated off the main entrance hall which allows service users to make telephone calls in private. Staff were seen to be courteous and helpful and service users were seen to be treated with dignity and respect by the staff during this inspection visit. Service users wishes regarding dying and death were seen to be recorded appropriately in the care plans. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13, 14, 15 Service users are supported to pursue a range of activities and are encouraged to maintain contact with friends and family. They are offered a choice of wellprepared, wholesome food and are supported by staff to exercise choice and control over their daily life. EVIDENCE: There is a full-time activities co-ordinator employed at the home and she has recently undertaken an activities training programme. She stated she is due to undertake a creative activities course run by Age Concern. She is enthusiastic and committed and said she enjoys her role and has bought many new games for the use of the service users. A weekly activities programme is displayed in the ground floor lounge. The activities co-ordinator said that she encourages service users to choose the activities they would like to participate in. If service users choose not to participate this is respected. Activities on offer include: painting, crosswords, bingo and reminiscence therapy. One service user particularly likes painting and was very enthusiastic about this during the inspection visit. The Manager said that the home has bought a new minibus which will be used to take service users out to local parks and shops. A service user spoken to stated they would love to visit the local parks. Service users were seen to be listening to and singing along to music on the day of inspection. The Manager said that three service users are going to Lourdes this year. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 14 Televisions and music equipment are available for service users in the communal areas. The home has a pet cat and one service user stated how important the cat was to them and how they gained immense pleasure from contact with the cat. Relatives are encouraged to maintain close contact with service users and some relatives choose to participate in the care and this wish is respected. Service users and their relatives were seen to be sitting in the garden engaging in conversation. A hairdresser visits the home weekly and some service users choose to visit hairdressing salons outside the home. Weekly and evening Mass takes place and service users may choose to participate. Food on offer on the day of inspection looked very appetising and included: leek and potato soup, roast leg of lamb, roast potatoes and cauliflower with an alternative vegetarian food choice offered. A dessert was also offered. All service users spoken to praised the quality of the food. Meals were seen to be taken in a relaxed and friendly atmosphere, service users sat at small well-laid tables and were seen to communicate positively with each other during the meal. Visitors were invited to stay for meals for a small contribution. One service user said ‘I am very happy and comfortable here’. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16, 17, 18 There is an appropriate complaints procedure and this is accessible to service users. Complaints are investigated fully in accordance with this procedure. Service users rights are protected and systems are in place to protect service users from abuse. EVIDENCE: A complaints procedure is in place at the home and can be found in every copy of the Service User Guide. There is a complaints log available which is well organised and easy to follow; two complaints have been recorded since the last inspection visit. Both were seen to have been investigated and the action taken was recorded. The home has adopted the Local London Borough of Richmond Protection of Vulnerable Adults Policy and also has it’s own organisational abuse policy. There is a Whistle blowing policy in place. Service users can choose to have access to an advocate if they wish. The Manager stated that many service users have access to the services of a local solicitor. She informed the inspectors that all service users money is controlled by external representatives. Appropriate individualised risk assessments were found in the two care plans examined. Service user meetings take place at the home and the Manager stated she is going to increase the frequency of these meetings. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 16 Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 19, 20, 21, 23, 24, 25, 26 The environment at this home is clean, comfortable and homely. The large mature garden is beautifully maintained and the attractive conservatory is an asset to the home. Service users live in a safe, well-maintained environment. Their bedrooms are comfortable and they have their personal possessions around them. EVIDENCE: This home is a purpose built three-storey building owned by the Sons of the Divine Providence. It is a non-smoking environment. A spacious and attractive conservatory is situated to the front of the building, it contains a small feature fountain and leads into the lounge area which is homely and contains a fish tank, book cases, plants and ornaments. A cold water dispenser can be found in the conservatory. There is a large and bright dining room that is situated next to the kitchen and leads out to the garden. The Manager stated that new curtains have just been brought for the dining room. The kitchen was seen to be clean and organised. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 18 The large garden is well maintained and contains a pond and mature shrubs and trees. A secluded area to the side of the garden contains a grotto shaded by trees where open air Mass can take place. A staff member informed the inspectors that work to make the garden more wheelchair accessible has taken place recently. A chapel for the use of staff, service users and their families is situated across the garden. A service user spoken to said ‘the garden is beautiful’. Bedrooms were seen to be clean, comfortable and well personalised to individual taste on the day of inspection. Some shortfalls were noted: One bedroom was found to contain a loose electrical wire that requires fixing to the skirting board/wall. Bathrooms were seen to be sufficient to meet the needs of the service users however, two bathrooms floors were seen to be stained in areas and would benefit from replacement. The area of black staining above a lounge radiator should be addressed and the insulation on one bathroom pipe is becoming loose and will need to be repaired. All areas in the home were clean and hygienic on the day of inspection. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staffing levels and structure have improved and are appropriate to meet the needs of the service users. Staff are enthusiastic and committed to delivering high standards of care and they demonstrated a good knowledge of service users needs and displayed a conscientious attitude to their work EVIDENCE: The Manager reported that the home recently advertised for a deputy manager and they have not had a successful applicant. They have instead promoted a staff member so that the home now has four Senior Support Staff members. She said this additional support has been useful. The Manager also stated that she is looking at ways of developing individual staff member’s skills. There is a comprehensive staff induction programme in place at the home. All staff were seen to be interacting positively with service users and demonstrated a caring and conscientious attitude. A service user spoken to said that ‘all the staff are wonderful, polite and helpful’. Regular staff meetings were seen to be held and these are fully minuted. Issues discussed include: teambuilding, moving and handling and communication between staff members. Evidence was seen that staff supervision is taking place regularly and is being recorded. A staff member spoken to reported that they felt happy and supported. Three staff files were examined and the Manager said she is reorganising the files to include supervision and appraisals. One file seen did not contain a Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 20 photograph of the staff member. Another file did not contain an updated contract or job description. All the other information required to be in the staff files including references and identification was found to be in place. Evidence was also seen of annual staff appraisals taking place. There has been recent staff training in the areas of infection control, food hygiene and fire safety. The Manager said she is in the process of updating all the training records to improve the presentation of this information. She said a part of this process will include auditing all the staff training to ensure they remain up-to-date with their training needs. The Manager discussed the importance of training with the inspectors and said she would ensure staff remain updated in mandatory areas such as fire safety, food hygiene and moving and handling and also attend regular updates in abuse awareness and challenging behaviour. Fourteen staff including the Manager have an NVQ qualification. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 38 The Manager is experienced, enthusiastic and suitably qualified, her management style is open, inclusive and positive. The Manager provides clear direction and leadership within this home and has a good understanding of any areas needing improvement. EVIDENCE: The Manager is experienced and has been at the home for 12 years. She achieved the NVQ Level 4, is an NVQ assessor and works closely with the local college. She stated she enjoys this role and reads widely on social issues. She said the home has acquired computer since the last inspection visit and that this has been very beneficial. It allows her to carry out her role more effectively and it has helped her to improve upon the documentation including care plans. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 22 The Manager stated that the home has no input in service users financial matters and these are dealt with by external representatives such as family or solicitors. Although accident forms are being completed at the home, not all of these have been reported to the CSCI and the home did not have a log of all accidents occurring in the home. The Manager said she would address these issues. Some fire doors were seen to be held open with wooden wedges, these doors must be kept closed and not be wedged open. Fridge and freezer temperatures are being recorded appropriately. Hot water temperatures are being recorded weekly however temperatures at one outlet were found to exceed 43 degrees centigrade. Temperatures must not rise above this level. An up-to-date Portable Appliance Certificate was not in place and this testing needs to be carried out. However, up-to–date certificates were found in respect of Gas Safety, Legionnella, water servicing, fire alarms, electrical installation and the passenger lifts. Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 3 3 2 Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12 (1) 15 (1) (2) Requirement The Registered Providers should: 1. Ensure that information in the care plans including risk assessments is archived and remove any inappropriate documentation. 2. Ensure that all care plans are reviewed monthly. (Previous timescale of 30/04/05 not met). 1. The Registered Providers must 1st July ensure that the receipt of all 2005 medication is recorded accurately. 2. The registered person must ensure that the administration of all medication is recorded accurately and that the administration record reflects the current dose to be administered. The Registered Providers must ensure that all maintainence issues outlined in Standard 19 of this report are addressed. The Registered Providers must ensure that staff files contain all the information required in Timescale for action 1st September 2. OP9 13 (2) 3. OP19 23(2)(b) & (d) 19 (4) Schedule 4 1st September 2005 1st September 2005 Page 25 4. OP29 Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 5. OP38 37 Schedule 4 of the Care Homes Regulations 2001. (Previous timescale of 30/04/05 not met) The Registered Providers must ensure: 1. That the Commission for Social Care Inspection is notified of all events in accordance with Regulation 37. 2. A log is kept of all accidents in the home. The Registered Providers must ensure that hot water temperatures do not exceed 43 degrees centigrade. The Registered Providers must ensure that an up-to-date certificate for Portable Appliance Testing is in place. The Registered Providers must ensure that fire doors are not wedged open. 1st August 2005 6. OP38 13 (4) 1st July 2005 1st July 2005 1st July 2005 7. OP38 13 (4) 8. OP38 13 (4) 23 (4) 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 OP7 OP9 Good Practice Recommendations The Registered Providers should ensure that out-of -date risk assessments are archived. 1. It is recommended that the reason for disposal be recorded when large amounts of medication are returned. 2. It is recommended that all eye preparations be labelled with the date when opened. 3. It is recommended that treatment cards be available for al service users prescribed warfarin Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon SW19 3RG 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 Orione House G54-G04 S17385 Orione House V221934 080605 Stage 4.doc Version 1.30 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!