Inspection on 04/10/06 for Ormerod Home Trust

This inspection was carried out on 4th October 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ormerod Home Trust 15/09/05

Ormerod Home Trust 24/09/04

Ormerod Home Trust 18/06/04

Similar services:

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Clover House

Parkside

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

CARE HOME ADULTS 18-65 Ormerod Home Trust 56 St Patricks Road South St Annes Lancashire FY8 1XN Lead Inspector Lesley Plant Unannounced Inspection 4th and 6 October 2006 10:45 th Ormerod Home Trust DS0000010045.V308076.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 DS0000010045.V308076.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 DS0000010045.V308076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ormerod Home Trust Address 56 St Patricks Road South St Annes Lancashire FY8 1XN 01253 723513 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 Ms Bonita Green Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: 56 St Patricks Road South is registered to provide support for four people with learning disabilities. The home is situated in a residential area of St Annes, within easy reach of local amenities. The property is a dormer bungalow, with full wheelchair access on the ground floor. The registered provider is the Ormerod Trust, which operates a number of residential and community based services in Lytham St Annes and the surrounding area. The service is guided by the policies and procedures of Ormerod. Ormerod Home Trust DS0000010045.V308076.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, took place during two visits to the home and looked at the key national minimum standards, plus supervision arrangements for staff. At the time of the inspection there were four service users living at the home. The inspector spoke to the team leader; the senior support worker and four of the support workers. Records were viewed and a tour of the building took place. The four people living at the home have specific communication needs and therefore discussion with individuals was not possible. Time was spent observing staff and service users engaged in daily activities. Comment cards providing feedback were received from one relative and one social care professional in contact with the home. Information was also gained from a pre inspection questionnaire completed by the registered manager. A visit to the organisation’s main office also took place, where recruitment and training records were examined. What the service does well: Person centred planning is now well established at St Patricks Road South, meaning that service users’ dreams and wishes are identified and worked towards. Each service user has a useful communication profile detailing how they express themselves and the interpretation of various personal nuances. Some of the team have undertaken specific communication training and communication is also explored during induction and NVQ programmes. The four people living at the home have specific communication needs and staff work hard in this area. Arrangements for the safe keeping of money are good, with regular monitoring taking place. Ormerod provides an excellent staff-training programme. Training is organised by a dedicated training team based at the main office. Discussions with one of the new members of the team confirmed that an excellent induction programme is also provided. The supervision and appraisal system is excellent, meaning that staff are well supported and guided in their work. The home is well run, with good systems in place and information maintained in an organised manner. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Each service user an individual service plan, which details the support required with personal care, social support and healthcare. This guides staff in their day-to-day work and is particularly useful for new staff. The individual service plans have not been reviewed or updated for over 12 months and this must be addressed. Risk management strategies need strengthening. Bedrails are being used for one individual and although this has been discussed and agreed with his nearest relative the potential risks have not been thoroughly addressed. Any use of such equipment must be properly considered and risk minimising action must be in place. The use of stair gates must be fully risk assessed, with advice from the fire safety department. A medication prescribed for one person to take when required, had not been included on the medication administration record and medication administration records had not been completed for the evening prior to the first visit of this inspection. Although the general medication procedures appear good, there are a number of improvements, which should be made. The landscaping of the garden will make a big improvement and progress with this work should be monitored. The home has been without a registered manager; this absence being covered by another experienced manager. The provider organisation is reviewing its management structure and it has been agreed that this temporary management cover can continue in the short term. Once management arrangements have been decided, a manager must apply for registration with the CSCI. Four of the nine support workers have achieved an NVQ qualification and it is anticipated that the home will soon have over 50 of the team qualified. Ormerod Home Trust DS0000010045.V308076.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. Ormerod Home Trust DS0000010045.V308076.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 Ormerod Home Trust DS0000010045.V308076.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 good. This judgement has been made using available evidence including a visit to the service. Well-established assessment and introductory processes, ensure that needs are assessed and only suitable placements are made. EVIDENCE: The provider organisation has well-established processes in place, which ensure that a thorough assessment of needs takes place before new service users are admitted. The current service users have all lived at the home for over 12 months. The last person admitted to the home had previously lived within another service operated by Ormerod and was therefore well known to the provider organisation. 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. All introductions are planned and taken at a pace suitable to the individual. Evidence was seen that relatives and other involved parties are consulted and involved in the assessment and admission process. Ormerod Home Trust DS0000010045.V308076.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Person centred planning is established, however as individual support plans are not being regularly reviewed, changing support needs may not be being addressed. Service users are supported to make decisions. Some risk assessments and risk management plans are not thorough enough to provide adequate protection to service users. EVIDENCE: Ormerod Trust operates a well-established system of person centred planning. There are currently four people living at the home and the person centred planning records for each person were examined. A“ listen to me” or a “changing days” workbook is completed and time is spent with the individual helping them to identify goals and wishes for the future. Pictures and photographs are used to aid this communication and to make the process meaningful to the person involved. Relatives and supporters are involved as appropriate. Photos and displays from the last planning meetings were viewed, as well as the written person centred planning minutes, containing the list of goals which have been agreed. Key workers then complete monthly or bi monthly progress records to monitor progress towards achieving the goals Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 11 identified. The process is working well at St Patricks Road, however the Team Leader should monitor the written progress updates as for one person these updates did not clearly show progress towards all of the goals identified. Each person also has an individual service plan, which details the support required for aspects of daily living, such as personal care, social support and healthcare needs. This guides staff in their day-to-day work and is particularly useful for new staff. The individual service plans had not been reviewed or updated for over 12 months and this must be addressed. For one person, exercises recommended by a physiotherapist had not been included in this care plan. Although the exercise programme was being followed it is important that changes such as this are included within the written individual service plan, which must be reviewed at least every six months. The four people living at the home have specific communication needs. A communication passport has been developed for each service user, which includes an interpretation of behaviours and descriptions of how the person may respond to different situations. Two people at the home have individual communication aids. For one person this is a folder with removable pictures and for another it is a board containing objects relating to certain regular daily activities. Staff work hard, with the use of these aids, to involve service users in decision making within the home. Staff undertake communication training as part of the Ormerod core training programme and communication is also explored during induction and NVQ programmes. The communication aids and training help staff to interpret the wishes and decisions of those living at the home. The relative who completed a feedback comment card for the inspection confirmed that he is kept informed of important matters and consulted regarding certain decisions. A number of risk assessments are in place and these have been reviewed in July 2006. A wide range of issues are addressed including; swimming, travelling in a car, the use of certain crockery for one individual and the potential dangers of hot water. Bedrails are being used for one individual and although this has been discussed and agreed with his nearest relative the potential risks have not been thoroughly addressed. 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 entering another’s’ room. This does not address any potential risks but merely states why it is being used. A gate has also been fitted at the bottom of the stairs to prevent one person falling if attempting to use the stairs. The use of the stair gates and bedrails was discussed with the Team Leader. Whilst acknowledging that such equipment has been installed for the protection of service users and the consent of relatives has been obtained, thorough risk assessments must be in place and regularly reviewed. In addition, advice should be sought from the fire safety department regarding the use of the stair gates. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 12 Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities are arranged according to people’s preferences and staff provide good support to ensure that family links are maintained. Service users benefit from a varied diet and appear to enjoy the meals provided. EVIDENCE: Staff support service users to take part in meaningful and appropriate activities. The current service users each have some individual funding for one to one support. This is mainly used during the daytime to enable each person to take part in suitable activities of their choosing. Service users have an individual weekly plan of activities, which reflects their own likes and preferences. The Person Centred Planning process helps to identify and maintain existing interests and also encourages the exploration of new activities. For one person, a desire to get internet access at the home was raised at his last planning meeting and this is being explored. Ormerod operates a resource centre, which is accessed by some service users at the home. Activities here include music therapy and a course, leading to a Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 14 nationally recognised award, which promotes personal development and independence. Service users also take part in activities in the community. A variety of community amenities are accessed. On the first inspection visit two service users were going swimming, one was attending a sensory drama class and one was at the resource centre. Good records are kept of all activities undertaken and these include bowling, swimming, eating out, shopping and the cinema. Staff rotas and observation during the inspection visits show that three staff are on duty during the day and two staff on duty each evening. This daytime staffing allows for individual activities to take place. During the second visit to the home, which took place during the afternoon/evening there were two staff on duty and due to the level of support service users require it would be difficult to go out. It is advised that the arrangement and timing of staff support hours be continually reviewed in order to ensure that the best use is made of the hours available. Holidays and short breaks take place and reflect the personal interests and needs of each service user. Ormerod provides a mini bus and a car, which staff can book when arranging trips out. Staff support individuals to maintain relationships and links with their family. Friends and family members are welcome to visit at any time and the staff are active in ensuring that good communication is established and maintained. A record is kept of all contact with relatives. Assessment and care planning information includes details of who individuals have close links with. Ormerod representatives are closely involved with the Fylde and Wyre Partnership board and people at the home can attend the monthly disco arranged by board members. The organisation also provides staff training regarding working with families. The relative who completed a feedback questionnaire for the inspection confirmed that he is kept informed of important matters and consulted about his relatives care. Relatives are involved in the person centred planning process and are invited to these meetings. Ormerod, the provider organisation held a family day at their head office earlier in the year. Information about the organisation was displayed and staff were available to talk to relatives and answer any questions. Daily routines at the home are flexible and are adapted to fit in with the days’ activities. Involvement with domestic tasks varies from person to person according to their abilities and motivation. One of the current service users is more involved with this and is supported by staff to do certain household tasks. Communication aids are being used for two service users, with the aim of increasing choice and self-determination regarding daily living activities. A photo board in the dining room displays pictures of the staff who are on duty that day, meaning that service users are aware of who will be helping them. Assessment and care planning documentation includes likes and dislikes regarding meals. The staff team advocate healthy eating and monitor service users weights, with records being kept. One of the current service users enjoys Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 15 grocery shopping and accompanies staff on shopping trips. A ten weekly menu is in place, providing a wide range of meals and acting as a guide for the food shopping. Service users also enjoy eating out in pubs, cafes or restaurants. Although staff have to carry out the majority of kitchen tasks, service users are encouraged to help, according to their wishes and capabilities. One person has certain food allergies, which are recorded on his care plan. Three people living at the home require some assistance at meal times and specific cutlery and plates have been purchased to promote independence in this area. Staff were observed providing assistance in a calm and sensitive manner and service users appeared to enjoy the meals provided during both inspection visits to the home. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Personal care and health care needs are met. Medication arrangements could be improved, to minimise the risk of errors or confusion. EVIDENCE: The current service users require full support with their personal care needs. Staff undergo training regarding this intensive personal care. Personal care needs are detailed within the individual support plan for each person. Times for going to bed and getting up are flexible and vary according to the activities planned for each day. Additional advice and support such as for physiotherapy, communication and specialist equipment, is accessed as appropriate and a key worker system is established at the home. Ormerod has developed a policy regarding consent to medical treatment. Protocols are in place regarding specific needs, such as for service users with epilepsy. Each file contains records of appointments, such as GP, chiropody and dentist visits. Staff also keep good records of seizures, continence and weight, which means that changes can be responded to. Medication is stored in a locked cupboard within the staff sleep in room/office. Staff have completed appropriate training, initially as part of their induction Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 17 programme, with more in depth training following on. Staff have also completed specific training regarding administering certain rectal medication. The training records at the main office show when refresher training is due. Drug information leaflets are available for staff information. Although the general procedures appear good, there are a number of improvements, which should be addressed. A medication prescribed for one person to take when required, had not been included on the medication administration record. This should have been handwritten on the administration record and checked and signed by two members of staff. Medication administration records had not been completed for the evening prior to the first visit for this inspection. This appeared to be an oversight in an otherwise good recording system. The majority of medication is supplied in blister packs, however the staff are advised that any medication not in the blister pack, should be dated upon opening. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for handling complaints are in place. Policies, procedures, good practice and staff training promote the protection of those living at the home. EVIDENCE: There have been no complaints since the last inspection. A complaints procedure is in place. This is produced in plain text and with pictures, to aid the understanding of service users. Good contact is kept with relatives, who would advocate on the individuals behalf if necessary. The relative who completed a feedback questionnaire for the inspection responded that although he has never felt the need to complain, he is aware of the complaints procedure and who to contact if their were any concerns. The provider organisation has procedures in place, which promote the protection of those using the service. Staff recruitment includes appropriate checks. Arrangements for the safe keeping of money are good, with regular monitoring taking place. The finance records and money held for two service users were examined, with a minor discrepancy being addressed by the time of the second inspection visit to the home. New staff undergo structured induction training, which addresses issues of abuse and protection. This is also covered within NVQ programmes. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The property is attractive and provides a homely environment for service users. The home is clean, attractive and well maintained. EVIDENCE: The home is situated within walking distance of St Annes centre, giving easy access to a range of local amenities. The home is a dorma bungalow, with full wheelchair access on the ground floor. There are two service users bedrooms on the ground floor and two on the first floor, with a bathroom on each floor. A number of bedrooms have recently been decorated. Communal space consists of a kitchen, dining room and lounge. Bedroom furnishings and decoration reflect the interests and needs of each person. There is a small enclosed yard at the rear of the home, with large more open gardens at the front and side of the building. At the time of the visit work had started on re landscaping this larger garden area in order to make it more suitable and usable for the current service users. The dining room decoration is a little tired and staff confirmed that there are plans in place to decorate this room. Domestic staff are not employed at the home, as support staff carry out cleaning tasks as part of their day-to-day work. The home was clean and staff Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 20 are clearly working hard to maintain good standards within the home. There is a separate laundry area in an outbuilding accessed from the rear yard. Staff undergo infection control training within the induction programme and this is also covered within NVQ training. There are infection control procedures in place and protective clothing is provided. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 21 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 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Excellent training opportunities and supervision arrangements mean that service users are supported by a competent staff team. Well-established recruitment practices are in place. EVIDENCE: There are nine staff on the support team, including one senior support worker. NVQ training is promoted, with four members of the team having achieved level 2 or above. Three staff are working towards the level 2 award. The two newest members of the team are undertaking the Learning Disability Award Framework induction, whilst completing the six-month probationary period required by the provider organisation. Discussions with one of the new members of the team confirmed that an excellent induction training programme is provided. Ormerod also provides excellent opportunities for qualification training, which is highly valued by staff. Staff undergo communication training and demonstrated good communication skills during both inspection visits to the home. The social care professional who completed a feedback comment card for the inspection confirmed that staff communicate clearly and demonstrate a good understanding of service users needs. The files for the two recently appointed staff were viewed and evidenced that appropriate recruitment practices are being followed. Documentation includes Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 22 an application form, two references, criminal records bureau disclosure, health questionnaire, and emergency contact details. Ormerod operates a six-month probation period. A number of people supported elsewhere within Ormerod services have received training and are involved in staff selection. Following this process applicants are invited to visit the home to meet those living there. Ormerod provides an excellent staff-training programme. Training is organised by a dedicated training manager based at the main office. Records show that new staff follow a seven-day induction programme, which covers the Learning Disability Award Framework induction standards. Staff are then encouraged to register for NVQ programmes, once the six-month probation period has passed. The induction of new staff also includes a house based induction programme, with a checklist showing when each topic has been covered. There is a rolling programme of core training, with dates being set for the year. This covers topics such as moving and handling and first aid. A training matrix for the organisation shows what training has been completed and when refresher courses are due. Records show that each staff member has signed a supervision agreement. The senior support worker receives regular supervision from the team leader and has also had an appraisal meeting. The senior support worker works hard to carry out supervision sessions with support workers at the home. Records show that supervisions take place approximately every four to six weeks, that an appraisal takes place at the end of the six-month probation period, and then appraisals take place annually. Supervision meetings address various topics, including training and identify any action required. The minutes of regular staff meetings were also viewed. These address a wide range of topics, with the last meeting including specific communication methods being used for one individual at the home. The supervision and appraisal system is excellent, meaning that staff are well supported and guided in their work. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management and quality monitoring arrangements help to ensure that good standards are maintained. Staff training, policies and good practice promote the health and safety of those living and working at the home. EVIDENCE: The home has been without a registered manager, this absence being covered by another experienced manager, who is registered with the CSCI in relation to other care homes operated by Ormerod Trust. The provider organisation is reviewing its management structure and it has been agreed that this temporary management cover can continue in the short term. Once management arrangements have been decided a manager must apply for registration of this home with the CSCI. Regular staff supervisions, staff meetings and quality audits take place and there is a senior support worker based full time at the home. The home is well run, with good systems in place and information maintained in an organised manner. Ormerod Home Trust DS0000010045.V308076.R01.S.doc Version 5.2 Page 24 There is a range of external and internal quality monitoring systems in place. Ormerod has gained and maintained the Investors in People Award and is affiliated to the Quality Network, which carries out innovative quality monitoring work, with the full involvement of service users; although there has been no recent involvement with the Quality Network at St Patricks Road. Staff and service users from Ormerod are represented at learning disability and community partnership forums, where there is opportunity to contribute to wider planning and decision-making. Internal systems include a suggestion box in the reception of the main office, regular quality audits and formal visits to comply with regulation 26 of the Care Homes Regulations. The team leader, with temporary management responsibility for the home, carries out the quality audits and records of these were viewed. Regulation 26 visits take place, however these reports are not always being sent to CSCI as required. Person centred plans are in place and are updated annually, giving a natural opportunity to gain feedback about the service provided. Social workers and relatives are involved in this process. The provider organisation has a designated member of staff, who undertakes monthly health and hygiene audits of the home, with a report being compiled. These visits focus on food hygiene, food storage and cleanliness. The wellorganised training programme addresses key areas of health and safety. A recently appointed member of staff confirmed the quality of this rolling programme of training, which also includes fire safety training. The pre inspection questionnaire confirmed that maintenance checks are complied with. Records viewed included, the testing of electrical appliances certificate, the gas safety certificate, the fire procedure, record of fire equipment maintenance and a record of fire drills. Fridge and water temperatures are monitored and recorded, however records show that these have not been completed during the past few weeks and this should be addressed. There are risk assessments in place regarding potential hazards at the home. Ormerod Home Trust DS0000010045.V308076.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 2 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 2 x 2 X 3 X X 3 X Ormerod Home Trust DS0000010045.V308076.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. 2. Standard YA6 YA9 Regulation 15 13 Requirement Care plans must be regularly reviewed. Thorough risk assessment and risk management strategies must be in place and regularly reviewed. Accurate records of administering medication must be maintained. Accurate records of prescribed medication must be maintained. An application for the manager to register with the CSCI must made. Reports of the monthly regulation 26 visits must be sent to the CSCI. Timescale for action 24/12/06 24/11/06 3. 4. 5. 6. YA20 13 13 8 26 30/10/06 30/10/06 15/01/07 24/11/06 YA20 YA37 YA39 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 YA32 Good Practice Recommendations 50 of care staff should achieve an NVQ level 2. DS0000010045.V308076.R01.S.doc Version 5.2 Page 27 Ormerod Home Trust Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Ormerod Home Trust DS0000010045.V308076.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. 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