Inspection on 25/04/07 for Ormerod Home Trust

This inspection was carried out on 25th April 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ormerod Home Trust 27/11/08

Ormerod Home Trust 06/09/05

Ormerod Home Trust 16/06/05

Ormerod Home Trust 24/09/04

Ormerod Home Trust 11/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Ormerod Home Trust 3 Margate Road St Annes Lancashire FY8 3EG Lead Inspector Lesley Plant Unannounced Inspection 25th April 2007 2:30 Ormerod Home Trust DS0000010062.V331618.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 Ormerod Home Trust DS0000010062.V331618.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. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ormerod Home Trust Address 3 Margate Road St Annes Lancashire FY8 3EG 01253 723513 01253 723514 ssharples@ormerodtrust.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ormerod Home Trust Limited Miss Jayne Louise Morris Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Margate Road is a care home providing 24-hour personal care and accommodation for three adults with learning disabilities. The home is situated in a residential area of St Annes; it is domestic in character and in keeping with the local community. It is within easy reach of community amenities and transport links. There are two ground floor bedrooms. The service is guided by the policies and procedures of Ormerod and has a dedicated staff team. The home provides long-term placements and is committed to the person centred planning approach. The fees vary according to the staffing needs of each person at the home and currently range from £702 to £1337 per week. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the afternoon. All the key national minimum standards, plus supervision arrangements for staff were assessed. At the time of the inspection there were three people living at the home. The inspector spoke to three support workers and the three people living at the home. Two people living at the home have specific communication needs and therefore discussion with these individuals was limited. Records were viewed and a tour of the building took place. Information was also gained from a pre inspection questionnaire completed by the registered manager and from a feedback survey completed by a relative. A visit to the organisation’s main office also took place, where recruitment and training records were examined and further information was gained from registered manager. What the service does well: What has improved since the last inspection? Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 6 The staff team continue to provide a high quality service at Margate Road. 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. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 7 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 Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The well-established assessment and introductory processes ensure that new people are only admitted to the home if their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider organisation has well established policies and procedures regarding the assessment and introduction of new people and demonstrates good practice in this area of service provision. The written policy regarding admission to the service includes the giving of information, the terms and conditions of residency and a set assessment format. Information about the home is produced in a pictorial format and complimented by written material. Social work assessments are gained and Ormerod carries out their own thorough assessment. Relatives are involved as appropriate to the individual. Compatibility is given a strong focus and introductory visits take place at a pace suitable to the individual concerned. One person has been admitted to the home since the last inspection. This individual had previously lived in another care home provided by Ormerod and was well known to staff and the existing residents of the home, having visited regularly for some time. A member of staff explained how she had worked with Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 9 this individual at her previous home and had then transferred to Margate Road in order to provide continuity of support. Records showed that the original assessment information had been reviewed at the time of the move. Ormerod Home Trust DS0000010062.V331618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. Person centred planning is established, however as care plans are not being regularly reviewed, changing support needs may not be being addressed. People are supported to make decisions about their lives. Some risk assessments and risk management plans need strengthening, to ensure the protection of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place and give detailed information regarding the support required for all aspects of day-to-day living. These guide staff in their work and are particularly useful for new staff. At present care plans are being reviewed annually and this should be addressed to ensure that a full review of the care plan takes place at least every six months. There is some updating taking place outside of the annual review, with new needs such as a desire to attend church being responded to. However there should still be a full review of all aspects of the care plan, at least every six months. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 11 Each person also has a person centred plan, identifying dreams and aspirations for the future. Time is spent with the individual helping them to identify their goals. A real effort is made to ensure that the individual remains the central focus and information is presented in meaningful ways, such as using photographs and pictures. Relatives and supporters are also involved. The key worker then completes regular progress reports, approximately every two months. Person centred planning is well established at Margate Road and takes place annually. For one person, with limited verbal communication, a series of photos had been used to illustrate her likes, activities and achievements. The excellent arrangements for person centred planning are a real strength of the service. Individuals at the home are supported to make decisions about their lives. Each person has a communication profile, giving details of how they express themselves and guiding staff in how best to respond to individual communication needs. Two people at the home have limited verbal communication. During the inspection it was observed that photos of the staff on duty, were displayed in the kitchen, ensuring that the people living at the home were aware of who would be helping them that day. Some of the team have undertaken specific communication training and communication is also explored during induction and NVQ programmes. Staff have built up good working relationships with people living at the home, with one member of the team having worked with one person in her previous care home, also managed by Ormerod. This focus on communication helps to promote self-determination and supports individuals with decision-making. People living at the home have access to advocacy services. Although risk assessments are in place and are regularly reviewed, there should be improvements in this area. Bedrails are being used for two individuals and although written risk assessments have been completed, these lack detail and do not address the potential risks of using this equipment. Any use of such equipment must be properly considered and risk minimising action, such as ensuring the rails are appropriately spaced and regularly checked, must be in place. A risk assessment has been completed regarding the use of a stair gate to prevent an individual going upstairs. This does not address any potential risks but merely states why it is being used. A gate has also been fitted at the top of the stairs, however the staff spoken to were unsure if this was still necessary as it had originally been provided to meet the needs of someone no longer living at the home. Whilst acknowledging that such equipment will have been installed for safety reasons, thorough risk assessments must be in place and regularly reviewed. Potential fire safety issues also need to be taken into account regarding the use of the stair gates. Ormerod Home Trust DS0000010062.V331618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Activities are arranged according to people’s preferences and interests and family links are maintained. Meals take into account health needs as well as individual preferences. People are supported to take part in household jobs according to their wishes and abilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home are supported to take part in meaningful activities, as identified through the process of person centred planning. Person centred planning helps to identify and maintain existing interests and also encourages the exploration of new activities. The regular key worker updates, ensure that progress towards goals is monitored and that activities remain relevant to the person. One person living at the home has a love of music, as recorded on her file and attends music therapy sessions, as on the day of this inspection. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 13 The home is close to a range of community facilities, such as the library, churches and shops. Staff have a role in helping to maintain relationships with neighbours and an example of this was discussed with the registered manager. As well as community facilities, the people living at the home can also access the resource centre run by Ormerod, where a variety of educational and leisure activities take place. Each person has a certain amount of one to one staff support during the day, which means that individual preferences can be met. In the evenings there are usually two staff on duty. Ormerod have a car, which staff can use to enable people living at the home to travel further afield and there are also arrangements in place for staff to use their own cars for such trips. People are involved in a range of community activities and good records are kept of all activities undertaken. A relative commented, “They (the staff) are excellent with the welfare and needs of my daughter, and also she leads a very good social life which is important to ***** and contact with old friends.” Files contain good information regarding family and friendships, which includes details of birthdays. One person with relatives living out of the area is supported to maintain regular phone contact and staff also take her to visit her family. Comments from a feedback survey completed by one of these relatives show that these efforts are appreciated. Ormerod, the provider organisation arranges family and friends events, when relatives are invited and are able to keep up to date with service developments. Relatives are also invited to person centred planning meetings. A record is kept of all contact with relatives and a number of staff have undertaken training, regarding working with families. Daily routines are flexible and vary according to the planned activities for each day. Each person has a large bedroom, with space for music/television systems, meaning that they can choose to spend time in one of the communal rooms or have privacy in their bedroom. Involvement with domestic tasks varies from person to person according to their abilities and motivation. Files contain information regarding likes and dislikes and staff are aware of any food preferences. Menus are flexible, serving as a guide for the weekly shopping. Individuals help with food shopping and meal preparation according to their wishes and capabilities. Staff take on the main responsibility for cooking, with the people living at the home either watching or taking part in some elements of food preparation. During the inspection visit, one person was supported to bake cakes and appeared to enjoy this activity. People also enjoy eating out in pubs, cafes or restaurants. Following specialist assessment by the speech and language therapist, one person has a soft or blended diet, with a thickening agent being added to Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 14 drinks. The community nurse has been involved in drawing up a risk assessment for this. Guidance is available for staff, who were observed following the agreed procedure, giving drinks with a spoon. Due to health problems, another person has a prescribed food supplement and staff keep very good records of her food intake. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Good monitoring, recording, staff training and consistency, result in people receiving a high standard of personal and health care support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three people currently living at the home all require a high level of support with their personal care. Each person has a named key worker, which helps to ensure consistency. One person has a specially designed chair and another has a pressure-relieving mattress on her bed. Records show that specialist advice is sought when necessary. Times for going to bed and getting up are flexible and vary according to the activities planned for each day. Files contain good information regarding health care needs. These include multi agency health care assessments and health action plans. The three people currently living at the home all have health problems and staff work hard to provide a consistently high standard of support. Good records are maintained and these include records of seizures, continence and weight. A seizure Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 16 management plan is in place, guiding staff in how to respond to this area of need. One person has unresolved health problems and staff are proactive in ensuring that appropriate investigations take place and that other professionals are kept informed and involved in this persons health care. The speech and language therapist has been involved with one person, to offer guidance regarding difficulties with swallowing and the learning disability community nurse also has contact with the people living at the home. Guidance from other professionals is followed, as observed during this inspection. Some members of the team have undertaken training regarding palliative care and bereavement. There is a high standard of health care support. Record keeping, contact with other professionals, individual protocols for specific areas of health care and the focus on health issues within person centred plans all ensure that people get the best possible health care. The staff member spoken to confirmed receipt of training regarding medication and the records held at the main office show when refresher training is due for all staff. A list is kept at the home, detailing the names of staff who have been deemed competent to administer medication. Medication is safely stored in locked drawers within the sleep in room, which is also kept locked. The medication administration sheets viewed were appropriately maintained. Medication information leaflets are available for staff information. Labels are available to use on containers, when medication is taken out of the home, such as on a day trip out. Staff were advised to use a code and record when medication, to be given when required, is not administered, instead of leaving the record blank. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Individuals are able to raise concerns. Policies, good practice and staff training help to promote the protection of those living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been received since the last inspection. A complaints procedure is in place, with a version available, which uses pictures and symbols in order to make the process of raising a concern easier for those living at the home. Individuals have opportunities to talk to a senior manager during monthly visits to the home and self-advocacy is promoted. The relative who completed a feedback survey for the inspection confirmed they would know how to raise a concern should they be unhappy. Policies and procedures are in place regarding abuse, protection and whistle blowing. Staff training addresses issues of abuse and challenging behaviour, which is also covered in NVQ programmes. The robust and well established recruitment procedures and the regular checking of personal finances also help to protect people. The finance records for one individual were viewed, showing that staff keep a good account of all personal income and expenditure. Ormerod Home Trust DS0000010062.V331618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The home is clean, attractive and well maintained, providing a lovely environment for those living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and close to local amenities. The ground floor has a large kitchen/dining room, a lounge, two bedrooms and a shower room. The first floor has a further shower room; the staff sleep in room and the bedroom for the third person living at the home. The three bedrooms are all large and nicely decorated, according to individual preferences, with plenty of room for personal belongings. There are garden areas, plus a decked space at the rear of the home. Ormerod has a maintenance person/ decorator who carries out remedial work at the home. Any problems are either forwarded by staff or picked up on the monthly health and safety audit of the home. Some of the tiles in the ground Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 19 floor shower room are cracked and the registered manager is advised to consider this area when looking at the regular maintenance programme for the home. The staff on duty stated that there are plans to upgrade this room. The home is very clean and staff must work hard to keep this high standard as well as fulfil all other aspects of their role. Staff carry laundry through the kitchen in order to access the washing machine and tumble drier, located in the garage. Infection/hygiene issues were discussed with two of the staff, who expressed good common sense knowledge and confirmed that preventative measures were in place, such as wearing protective clothing for certain tasks. There are arrangements in place for the collection of clinical waste and staff have undertaken health and safety and food hygiene training. Ormerod Home Trust DS0000010062.V331618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is excellent. Qualified, capable and well-trained staff, who receive excellent guidance and supervision from managers, support the people living at the home. The robust recruitment procedures help to maintain this high standard of staffing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The team consists of seven support workers, including a senior support worker who carries out some managerial tasks at the home. The registered manager oversees the work of the team. All the staff are qualified, having achieved NVQ level 2 or above, exceeding the target of 50 qualified as detailed in the National Minimum Standards. During the inspection there was a changeover of staff, with staff leaving at the end of the day shift and the evening staff commencing work. The inspector therefore had opportunity to meet five of the team. Staff were respectful and courteous, ensuring that they spoke with the people living at home as soon as they came on duty, prior to getting any necessary information from the staff finishing duty. Staff have good communication skills and clearly know the people living at the home very well. The atmosphere was relaxed and the relationships between staff and individuals living at the home appeared to be positive. Records are kept of any Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 21 contact with other professionals, such as the speech and language therapist and the community nurse. Ormerod has well established recruitment procedures in place. Recruitment records for one member of staff were viewed. Records include; an application form, a pre employment health questionnaire, details of the interview, evidence of criminal records bureau clearance and two references. Ormerod operates a six-month probation period. A number of people who are supported by Ormerod have received specific training and are involved in staff selection. Ormerod provides excellent training opportunities for staff. The organisation has a dedicated training team, which also provides training for other social care providers in the area. Staff undertake Learning Disability Award Framework accredited training and then move onto NVQ awards. A member of staff, in post for nine months, having already achieved NVQ qualifications and with many years experience in social care, explained how she had still undertaken the Learning Disability Award Framework training following her appointment with Ormerod. This was to ensure that she was fully equipped to work with people with a learning disability and to help her to transfer her existing knowledge and skills. There is also a good programme of core training, which includes all key areas of health and safety. Training regarding specific needs is arranged according to the individual needs of those living at the home. The training programme is well organised and refresher and update courses are provided. Excellent training records are maintained. A training matrix for the organisation shows what training has been completed and when refresher courses are due. There are excellent supervision arrangements in place for staff. Each staff member signs a supervision agreement and all meetings are recorded. Records show that supervisions take place approximately every month and address various topics, including training, and identify any action required. The senior support worker, who has monthly supervision meetings with the registered manager, carries out supervisions for the team. There is a good appraisal system in place. Appraisals include a self-appraisal and a personal development plan. The records viewed showed that there is an appraisal to mark the end of the six-month probationary period and then appraisals take place annually. Monthly staff meetings take place and minutes of these were viewed. The supervision and appraisal system is excellent, meaning that staff are well supported and guided in their work. Ormerod Home Trust DS0000010062.V331618.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. Strong management and the excellent monitoring and quality assurance systems ensure that a high quality service is maintained. Staff training, policies and good practice promote the health and safety of those living and working at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well run, with good systems in place and information maintained in an organised manner. The registered manager has worked for Ormerod for many years and has gained the Registered Managers Award, NVQ level 4 in Care and NVQ assessor and verifier qualifications. During discussion, it was confirmed that regular update training is also undertaken, as seen on the training matrix for the organisation. The registered manager is very Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 23 experienced and works hard to uphold the working practices and standards expected by Ormerod. A senior support worker at the home also carries out certain managerial tasks. Regular staff meetings and supervision sessions take place. The range of quality monitoring systems is excellent. There are internal and external quality monitoring systems in place. Ormerod has achieved the Investors in People Award and is also affiliated to the Quality Review network, which carries out quality monitoring work with and for people with learning disabilities. The most recent work of the review team has been focussed on the lives of people within the area who have complex needs and work is soon to start regarding looking at the experiences of people who challenge services. There is a suggestion box in the entrance to the Ormerod main office, inviting ideas and feedback about the service provided. The registered manager carries out a monthly audit and a senior manager within the organisation undertakes monthly visits, with reports being sent to the CSCI. Copies of both these different monitoring reports were viewed. The registered manager’s audit includes the monitoring and relevance of policies, which helps to ensure that they are appropriate and being put into practice. Questionnaires have recently been sent to all people using Ormerod services, including those living at Margate Road. This is another opportunity to gain feedback about the service provided. This questionnaire focuses on rights, choices and the support received. Ormerod has recently introduced a new logo for the organisation, with staff and people living at the home being invited to vote on the logo of their choice, showing that the views of people who use the service are valued. Staff and people who use Ormerod services are represented at learning disability and community partnership forums, where there is opportunity to contribute to wider planning and decision-making. Person centred planning is well established at Margate Road and is a vital element of quality assurance, giving all those involved, including relatives, an opportunity to give feedback about the service and to support the individual to plan for the future. The organisation has a health and safety manager, who carries out monthly visits to the home, producing a written report highlighting any areas for improvement. Staff training is in place regarding all key elements of health and safety. The fire book was viewed. Fire drills take place approximately every month and staff also undergo training in this area. Staff monitor fridge and freezer temperatures with records being maintained. Water temperatures are also regularly monitored. The pre inspection information completed by the registered manager confirms that the electrical wiring was checked in September 2006, the central heating system checked in July 2006 and fire equipment checked in May 2006. There are appropriate health and safety Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 24 policies in place. There are risk assessments in place regarding potential hazards at the home. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 25 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 3 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 4 33 X 34 3 35 4 36 4 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 26 NO 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 YA9 Regulation 13 Requirement Thorough risk assessment and risk management strategies must be in place. Timescale for action 10/06/07 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 YA6 Good Practice Recommendations Care plans should be reviewed at least every six months. Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Ormerod Home Trust DS0000010062.V331618.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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