Inspection on 21/05/07 for Ormonde Home For The Elderly

This inspection was carried out on 21st May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ormonde Home For The Elderly 16/05/08

Ormonde Home For The Elderly 15/12/05

Ormonde Home For The Elderly 29/09/05

Ormonde Home For The Elderly 27/01/05

Ormonde Home For The Elderly 16/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ormonde Home For The Elderly 44 Westerfield Road Ipswich Suffolk IP4 2UT Lead Inspector Deborah Kerr Unannounced Inspection 21st May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ormonde Home For The Elderly Address 44 Westerfield Road Ipswich Suffolk IP4 2UT 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) 01473 215073 01473 253969 ormonde.manager@virgin.net Ormonde Home for the Elderly Mr Keith Peck Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: Ormonde Home for the elderly was first registered in 1978. The home is owned and administered by The Brethren, a Christian charitable non-profit making trust. The building is a large converted Victorian detached house, which overlooks Christchurch Park in Ipswich. The home is reasonably close to the town centre. There are twelve single bedrooms and one shared bedroom, with all rooms having en suite facilities. People have the use of a lounge, dinning room and a conservatory. The bedrooms are located on the ground and first floors; the home is equipped with a shaft lift. There is limited parking to the front of the property, with on road parking nearby. The large garden to the back of the property is attractive and enjoyed by the people living in the home. A detailed statement of purpose, colour photographic brochure and a service user guide provides detailed information about the home, the services provided and access to local services. Each of the people living at the home has a contract of terms and conditions; which reflect the fees and how much they are expected to pay per month. Fees range from £375.00 – £501.00 per week, with additional supplements, depending on the assessed needs of the individual, for example a person assessed as requiring level 2 care pays an additional supplement of £42 per week and for those assessed as requiring level 3 care pay a supplement of £63 per week. These charges do not cover additional services such as the hairdresser, chiropodist and personal items such as toiletries, receipt of daily newspapers and personal transport. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and three quarters hours on a weekday. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including a pre inspection questionnaire and 13 Relatives/visitors comment cards and 10 residents ‘Have Your Say’ surveys. Additionally a number of records were inspected, relating to people using the service, staff, training, the duty roster, medication, health and safety and a range of policies and procedures. A tour of the home was made and time was spent talking with the deputy manager, three staff, two visitors and a seven people living in the home. What the service does well: What has improved since the last inspection? The home was approved in May 2006 by the Commission for Social Care Inspection (CSCI) to increase their registration from eleven to fourteen people. Refurbishment on the second floor has been completed providing accommodation for the additional people. The refurbishment included installation of a new assisted bath, shower area and toilet. Four bedrooms have been decorated and carpeted. A new separate water system has been installed in the roof, with new water mains and softener installed. Ramps to access the conservatory and the first floor have been installed and new fire doors fitted to the conservatory, dining room and main hall. All of this work has been completed to high standard and add considerably to the standard of accommodation. The home has been awarded a capital grant from Suffolk Association of Independent Care Providers for improving the care environment for older persons. This grant is being put towards the cost of replacing the armchairs in the lounge and conservatory. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6, People who use the service experience excellent quality outcomes in this area. People who may use this service have the information they need to make an informed choice about where they live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed statement of purpose; service user guide and brochure, which include colour photographs and information setting out the aims and objectives of the home and the services provided. Prior to moving into the home each person has a pre admission assessment completed. These provide detailed information about the individual’s health, social and personal care needs and determine if the home are able to meet the person’s individual needs. People who had recently moved into the home spoke positively about their experience. They felt they had received a warm welcome and were getting to know their way around and the other residents. One person commented “the staff are lovely, very helpful, I couldn’t ask for better, they have been very supportive helping me to move into the home at a very stressful time”. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 9 People’s files contained a written contract setting out the terms and conditions of residence, including a trial period, the method of payment and their current fee. A comment made by a person recently moved to the home was that the contract is very well written and easily understood. At the end of the threemonth trial period people have a review to ensure that Ormonde House is the right place to meet their needs. The minutes of the review indicate that the individuals concerned and their relatives spoke well of the home and felt they had been supported to make the transition into residential care. Included in the induction pack of a new member of staff was a guidance sheet to support a person moving into the home. The guidance covers a five-day period, which directs staff to prepare the person’s room with fresh flowers and a welcome card. On arrival the person is shown to their room and introduced to the other people living in the home and the staff. The designated member of staff is allocated time to spend with the individual discussing their preferred daily routines; likes and dislikes, hobbies and their life history. Information obtained during discussions with people and comments taken from the ‘Have Your Say’ surveys confirmed that people are given the opportunity to visit the home before deciding to move in. One person commented “ the information I received was good and being able to visit for lunch and stay a while made up my mind this was the home for me”. Another person told the inspector they had been able to choose the colour of the carpet and the colour of the paint to decorate their room, before moving in. Other comments included” I am more than satisfied with the love and care I receive” and “I am very happy to be at Ormonde House and I am sure the lord opened up the way for me to be here”. The home does not provide intermediate care; subsequently this standard is not applicable. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, People who use the service experience excellent quality outcomes in this area. The health and personal care people receive is based on their individual needs, although they cannot be assured that at the time of serious illness, death or dying their wishes will be respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three people living in the home were inspected. Each contained a current photograph of the person together with their personal details including next of kin and other important contacts. The plans are well organised, divided into seventeen sections which provide detailed information covering all aspects of the individual’s health, personal and social care needs. Observation throughout the inspection and the daily notes seen confirmed that the health and well being of people is being monitored. Regular visits were documented showing that people who are fit and well enough are supported to access their general practitioner (GP) and other local health services relevant to them. For people who are not well enough to leave the home arrangements are made for health professionals to visit them. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 11 The deputy manager demonstrated the process of administering medication. The Monitored Dosage System (MDS) is used and each blister pack had a front sheet with the individual’s details and a photograph for identification purposes. The quantity and date of medication received was seen entered on the Medication Administration Record (MAR) charts. Generally the process of receipt, administration and safekeeping of medication is well managed, however there was one missed signature on a person’s MAR chart. The manager was unable to confirm if the medication had been administered or if this was just an error involving the missing signature. This was discussed with the deputy manager whom agreed to conduct a monthly audit of medication to monitor the process to ensure medication is being administered safely and in compliance with the homes policies and procedures. None of the people living in the home are currently prescribed controlled medication. Each person’s care plan contains a risk assessment to determine if the individual wishes or is able to manage their own medication and the level of support required to achieve this. Of the three people’s plans seen, they had each chosen to have staff administer their medication. Staff were observed treating people living in the home with respect and dignity. The interactions between the individuals and staff were observed to be friendly and appropriate. Staff were observed calling people by their preferred name and responding sensitively to their individual’ needs and preferences. The home has a procedure in place guiding staff of the process to follow when a person living in the home dies. However this does not take into account the end of life needs of the people using the service. Although this is a sensitive subject this information needs to be ascertained and agreed with the individual to reflect their wishes to ensure that at the time of their death, staff will treat them and their family with care sensitivity and respect. The Gold Standards Framework was discussed with the deputy manager. This document is designed to meet the needs of people requiring palliative care, which supports the individual to manage degenerative and terminal illness through an established plan, which constantly monitors pain, distress and other symptoms to ensure the individual receives the care they need in accordance with their wishes and religious beliefs. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, People who use the service experience excellent quality outcomes in this area. People who use this service are able to make choices about their lifestyle, which enables them to live ordinary and meaningful lives, both in the home and in the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes brochure ‘emphasises that Ormonde House aim’s to provide a homely atmosphere which is in keeping with the individuals manner of life in the days when they were able to care for themselves’. On entering the home there is a noticeable happy and relaxed atmosphere, individuals were observed engaged in conversation with other people living in the home and the staff. Discussions with the people using the service confirmed that they are given the freedom and support where required to make decisions about how they spend their time, keeping to their own preferred routines and have day-to-day control over their lives. People were observed coming and going as they pleased. One person was seen returning to the home on a motorised scooter, they told the inspector they had been to town centre to go to the bank. Another individual was seen going out for a walk to post some letters. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 13 Essential to the ethos of the home, people have access to daily religious services, including a morning bible reading and an evening epilogue. People were seen gathering in the lounge for the daily bible reading and coffee. This was a very social occasion, which the majority of the people attend. One person commented “Ormonde House is perfect place for me, I have friends here and we support one another. We are able to participate in the range of religious activities within the home, my faith is very important to me”. The notice board in the entrance hall had an activities list providing the dates and the name of the person visiting the home to hold the evening epilogue and the dates of the twice weekly services held at nearby Ashcroft Hall. Transport to church meetings is provided by the home. Other activities include a fortnightly visit by the PAT dog’s and the community library, a monthly craft group, weekly armchair exercise group and outings to areas of interest. People are being supported to maintain links with the local community, conversation with an individual confirmed they are supported to attend their local Gospel Hall and remain as part of the fellowship which they have been involved with for many years. Another person confirmed they had lived local to the area for along time and showed the inspector that they receive fortnightly audiotapes of the Ipswich and District news to keep them updated on events and people. Visitors spoken with confirmed they are made welcome at all times. They felt the home is well run to suit the needs of the people living in the home. One described the home as “fantastic place for their relative” and the other visitor commented, “ This is a lovely home, my friend gets everything they need”. People spoken with described the food as “very good” and “we always have a choice of meals at dinner and tea, if we do not like either the cooks are very good they will provide an alternative, the service is first class”. Discussion with the cook confirmed meals are all ‘home-cooked’ using mainly fresh ingredients. The food store seen confirmed that the home has a good range of quality food. These were being stored in accordance with food safety standards. The menu for the day of the inspection was taken from a five week rolling menu and provided people with a choice of bacon chops or corned beef hash followed by a choice of spotted dick, baked egg custard, fruit and ice cream or yogurt. The cook was aware of the dietary needs of the individuals; a couple of people require a soft food diet and need their food puréed. The cook confirmed they puréed the meat and vegetables separately, however further discussion identified that they blended all vegetables together, it would be a better option for the individual to have these puréed individually so that they could taste the individual flavours as well as identify the vegetable by colour and texture. The lunchtime meal was observed; food served looked appetising and was nicely presented. Tables were nicely laid with flowers and napkins and matching the tablecloths, the mealtime was a sociable occasion with a lot of discussion and joviality. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, People who use the service experience good quality outcomes in this area. People can expect that their complaints will be listened to, taken seriously and acted upon and that procedures are in place, which protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The policies and procedures for dealing with complaints and safeguarding the people living in the home were seen. The complaints log confirmed there have been no complaints received since September 2003. Information in the complaints log indicates that the board of trustees investigated the complaint and that the complainant was satisfied with the outcome. The procedure for reporting allegations of abuse refers staff to the Suffolk Vulnerable Adult Protection Committee (VAPC), informing them to refer all allegations of abuse to Social Services, Customer First Team. However the whistle blowing policy needs to be amended to reflect the same procedure. The deputy manager was also advised that whilst the procedure remains the same the VAPC was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. Both policies relating to the protection of adults will need to be amended to reflect this change. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 15 People living in the home and staff spoken with confirmed they would go directly to the manager if they were unhappy about something. Staff also demonstrated a good understanding of what constituted as abusive practice and would have no problem reporting an incident or an individual if they had any concerns about their conduct. The home has a procedure for the management of people’s money and financial affairs. The home’s policy states they do not act as appointee for handling the financial affairs of the people using the service. Five people manage their own finances, one person is registered with the Court of Protection and the remaining people are supported by their next of kin or their representative. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,21,22,24,25,26, People who use the service experience excellent quality outcomes in this area. People can expect to live in a home that is decorated and presented to a high standard, which is comfortable and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ormonde House is a large converted Victorian detached house, which overlooks Christchurch Park and is reasonably close to the town centre. There is limited parking to the front of the property, there is a large attractive garden to the back of the house which is well maintained and enjoyed by the people living in the home. Following the morning bible reading people were seen sitting in the conservatory, which is to the side of the house and allows people to enjoy the view of the garden or if they wish and the weather permits, there is additional seating in the garden. The conservatory has a very homely appeal with plants, papers and magazines and personal items arranged belonging to the people living there. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 17 Additionally people have the use of a shared lounge and dinning room. Furnishings and lighting throughout the home are domestic in character and are sufficient for their purpose. The deputy informed the inspector that they have been awarded a grant and will be using this money to replace the armchairs in the lounge and conservatory. Following completion of the refurbishment of the home, there are twelve single bedrooms and one shared. Four bedrooms have been redecorated and carpeted. All bedrooms have en suite facilities comprising of a toilet and hand basin. Additionally there are assisted baths, walk in showers and toilet on all floors. All bathrooms and toilets provide grab rails for peoples safety and comfort. People’s rooms were nicely decorated and evidence was seen that they had brought their own possessions with them to personalise their rooms. All bedrooms are fitted with a call bell, door lock and lockable cabinet for personal items. Additionally people were seen wearing pendants linked to the call bell system so that they could call for assistance wherever they are in the home. A number of people spoken with showed the inspector their rooms, one person commented, “ I like sitting in my room as I have my own bird table outside fixed to the window ledge, so I can watch the birds”. Another commented “ I have the best room in the house, it is a lovely room, and have a good view over the garden”. They informed the inspector that they had brought their own reclining chair with them and had been able to choose the colour they wanted the walls to be painted and the colour of the carpet for their room. Further decoration and refurbishment of the home is in process. Ramps have been installed throughout the home to provide access for people using wheelchairs and other mobility aids. These are currently bare wood and require covering. The deputy advised with either non-slip flooring or carpet will be fitted. Plans are also in process for the lift between the first and second floor to be refurbished or replaced. Once this has been done the carpets on the second floor landing will be replaced. The home was found to be clean, bright and tidy with no unpleasant odours. A comment card, received prior to the inspection stated, “cleaners are first class and so helpful, however the net curtains could do with a wash, they are grey looking downstairs and at the front windows”. Other comments included “the domestics are very good they give my room a good clean, every day, they are very thorough and move my ornaments to dust, my en-suite is kept nice and clean and fresh” and “my visitors have been amazed at the freshness cleanliness of the home”. The laundry facilities seen were clean and tidy with appropriate equipment to launder clothing and bedding. The washing machine has a sluice facility for dealing with soiled linen. Appropriate hand-washing facilities of liquid soap and paper towels are situated in all bathrooms and toilets where staff may be required to provide assistance with personal care. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, People who use the service experience adequate quality outcomes in this area. Staff in the home are trained and skilled, however to ensure people are fully protected satisfactory checks against the Protection Of Vulnerable Adults register must be made and staffing levels reviewed to ensure there are adequate staff available to meet the needs of all people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several comments made in the residents and relatives/visitors surveys suggested that staffing levels are not sufficient to meet the needs of the people using the service. Comments included “the staffing levels seem low for current condition of residents, and “the home requires more staff to meet the needs of residents” and “ there are not enough carers, staff work very hard and attend to the care and support needs of people as soon as they can” another comment stated “generally there is sufficient staff, however, occasionally staff have seemed a bit stretched”. It was noted that two people were still in bed and waiting for assistance to get up when the inspector arrived at 9.30am. Discussion with the deputy manager confirmed that for one of the people this was their choice, however the other person required two people to help them with their personal care and had to wait until two carers were free, which restricts their freedom of choice regarding the time they get up. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 19 Staffing levels were examined as part of the inspection. The duty roster reflected that each day is covered by a senior who works between 8am - 4pm, supported by 2 carers between 8 - 2pm. The afternoon is covered by a senior who starts work at 2pm until 9pm, supported by 1 carer between 4 - 9pm. There is 1 waking night staff between the hours of 9pm – 8am, supported by a sleeping in person in case of emergencies. The manager and deputy manager also take it in turns to be on call at night. The deputy manager has been overseeing the day-to-day running of the home since March 2007 whilst the registered manger has been on sick leave. A discussion took place with the deputy about the difficulties they have been experiencing to staff the home. This has been due to covering staff’s annual leave, maternity leave and sickness. Information seen on the roster confirmed that the deputy is working on shift a minimum of three days a week and staff are working extra or double shifts to make sure the home is staffed. The deputy stated that they only use agency when they have to. To address the staffing problem they have recruited three relief staff, one commenced employment on the day of the inspection, however they are waiting for the recruitment checks to be verified for the other two before they can start work. Also to relieve some of the pressure from staff on the afternoon shift, one of the cooks is now being rostered providing extra support over the teatime period, preparing peoples food. Staff confirmed this has been a significant improvement which has freed up there time to spend with the people requiring assistance and support before, after and during their meal. Ormonde House currently has fifteen permanent care staff and four relief staff, 2 domestics, 2 cooks supported by 1 relief cook/domestic, plus the deputy and the registered manager. Seven staff have achieved their NVQ (National Vocational Qualification) level 2 awards and two staff have achieved their NVQ level 3 award in care. One recent recruited member of staff has a Certificate in Social Work (CCETSW). These figures reflect that Ormonde House has reached the National Minimum Standard (NMS) target of 50 of care staff to hold a recognised qualification. Records confirmed that staff are provided with training they need to gain the knowledge and skills to perform their work role and meet peoples needs. Most recent training has included Common Induction Standards, which covers principles of care, the role of and development of the worker, maintaining safety at work, effective communication, recognising and responding to abuse and neglect. Other training courses included first aid, food hygiene, fire precautions, moving and handling and administering medication. Staff files seen confirmed the home generally operates a good recruitment process, which includes obtaining all the appropriate paper work including Criminal Records Bureau (CRB), however two of the three staff files seen had not had a Protection of Vulnerable Adults (POVA) check requested when the CRB was applied for. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 20 People spoken with were complimentary about the staff and were confident that they met their needs. Comments included, “staff are just so lovely and friendly, they are wonderful, they do more and beyond what you normally expect” and “Nobody could be kinder than the staff here, they are marvellous, they never complain, if they can do anything for us they will, they are wonderful”. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,38, People who use the service experience excellent quality outcomes in this area. The home is run in the best interests of the people living in the home, which is tested by an effective quality monitoring system, however where concerns have been identified which compromise peoples health, safety and welfare actions need to be taken to minimise the risks and maximise people’s choice and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was absent on sick leave at the time of the inspection, however comments received by people living in the home and relatives confirm they remain competent to manage the home. They have previous experience of running a Christian Charitable home and has obtained relevant qualifications. The deputy manager has a National Vocational Qualification Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 22 (NVQ) level 3 in care and is working towards achieving the Registered Mangers Award (RMA). Comments received in the residents and relatives/visitors surveys described the management of the home as “an excellent home, we are very happy with the care” and “the manager is a wonderful person, so kind and understanding” and “we cannot speak highly enough of the care and attention given by the manager and the staff to the residents”. Other comments included “I find this home provides the love and care needed, everybody concerned is so kind and understanding” and “overall the standard of care and attentiveness is good, a lot of effort was put into helping my relative settle in and the care they received when they were unwell was excellent”. The home has good quality monitoring systems in place. The trustees carry out monthly, quarterly and bi annual reports. People who use the service and their relatives are asked to complete an annual survey. The deputy manager provided the Quality Assurance report for the year to March 2007. The report reflects that residents and relatives are satisfied with the service provided and that a dedicated staff team are doing their best to give an excellent service. Although the home does not manage people’s finances, for the convenience of three individuals the manager does hold a small amount of petty cash. These are held separately for each person and a record of transactions of all monies spent and received are logged. The records and balance for each person were checked and found to be accurate. During a tour of the home, it was noted that people are provided with safe, lockable cupboards where they can choose to store personal and valuable items if they wish. The deputy provided the inspector with a copy of the home’s business plan for 2002-2007, which reflects the financial status of the home. The plan sets out the reasons for making the alterations to the home to increase occupancy to 14 people. This work has now been completed in line with the plan. A new business plan needs to be agreed to demonstrate how the home intends to continue to be financially viable and continue to provide a quality service. New employees are expected to attend the Skills for Care Induction training, which is provided by the local authority. The home also issues each new employee with an induction pack. The pack is a comprehensive guide familiarising the employee with the layout, policies and procedures and health and safety arrangements of the home. This is used as part of a 4-week introduction into the home, followed by performance reviews at the end of months, 2,4,and 6. Evidence was seen in staff files that these review are taking place and supported by regular supervision. During the tour of the home a few minor issues relating to the safety and welfare of people living in the home were discussed with the deputy. Radiators on the ground floor in the entrance and near the lift are exposed and people could be a risk of burns if they fell against them. The window half way up the Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 23 staircase is at low level and opens outwards on to a roof. This could be a security issue or of concern if a person tried to get out of the window. One of the rooms on the ground floor has patio doors, which lead out into the garden. The person occupying the room told the inspector that the doors were kept locked as a safety precaution to prevent them falling down the steps. However this was not their choice and on a hot day would like to be able to have the doors open. These issues need to be assessed and actions identified to minimise the risks and to maximise people’s choice and independence. The home has made improvements for fire safety in the home. Extra fire detectors have been installed and new fire doors have been fitted to the conservatory, dining room and main hall. All fire doors operate on an automatic release, which is connected to the alarm system, which means doors will automatically close in event of the fire alarm being activated. The fire alarm system was tested during the inspection. This takes place on a weekly basis. Water temperatures are being recorded; these were tested and found to be within the safe recommended temperature of near to 43 degrees centigrade at various intervals during the day. Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 4 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 X 4 4 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 3 X 2 Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18 (1) (a) Requirement The manager must ensure that at all times there are sufficient numbers of staff working at the home to meet the needs of people living in the home. A review of all Criminal Record Bureau (CRB) checks must be made to ensure that staff have been checked against the POVA register. This will ensure the welfare and safety of the people using the service. All parts of the home which people have access must be free from hazards for their safety, and unnecessary risks identified and so far as possible eliminated. This will ensure the safety of people using the service and maximise their choice and independence. Timescale for action 22/05/07 2. OP29 19 (1)(b) (i) Schedule 2 13/07/07 3. OP38 13 (4) (a) (c) 29/06/07 Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 26 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 OP9 Good Practice Recommendations The home’s manager should conduct a monthly audit of medication to ensure medication is being administered safely and in compliance with the homes policies and procedures. Where food is pureed to meet the specific dietary needs of individuals each item of food should be puréed individually so that the individual can identify the food by colour and texture as well as taste the individual flavours. The whistle blowing policy needs to be amended to reflect the same procedure as the protecting adults from abuse policy. These will need to reflect that the Vulnerable Adult Protection Committee (PAVC) was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. 2. OP15 3. OP18 Ormonde Home For The Elderly DS0000024468.V341164.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Ormonde Home For The Elderly DS0000024468.V341164.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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