Inspection on 14/06/05 for Ormsby Lodge

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ormsby Lodge 04/12/08

Ormsby Lodge 09/02/07

Ormsby Lodge 13/03/06

Ormsby Lodge 11/01/05

Ormsby Lodge 02/09/04

Ormsby Lodge 07/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Ormsby Lodge 1 Ormsby Road Southsea Portsmouth PO5 2AL Lead Inspector Christine Hemmens Unannounced 14 June 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ormsby Lodge Address 1 Ormsby Road Southsea Portsmouth PO5 2AL 023 9273 8752 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr David Ernest Clarke Care Home 12 Category(ies) of LD - 12 registration, with number of places Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Service users in category LD are not to be admitted under 18 years of age. Date of last inspection 11 January 2005 Brief Description of the Service: Ormsby Lodge is a residential service providing care and support to twelve adults who have learning disabilities and complex behavioural needs. Ormsby Lodge is owned by Mr and Mrs Clarke who also own another residential service and a separate day service for service users with complex learning disabilities. Ormsby Lodge is a large period house set in a street of similar properties in a central location in Southsea. The house is set out over four storeys, the basement is used for storage and the service users accommodation is on the other three floors. The top floor has a small semi self-contained flat with a double bedroom and a single room, this can accommodate up to three service users who need limited support. There are further bedrooms on the first floor, two of which are doubles and there are four single rooms on this floor. There is one ground floor bedroom. The service does not accommodate people with physical disabilities or nursing needs. Service users are supported to use local amenities, which are a short walk away. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced visit to the home this year. The visit was held over one day. The inspectors were assisted with the visit by the residents, Mr and Mrs Clarke and senior care staff. The appointed manager is currently on long-term leave. The home has called upon an experienced senior carer to deputise in the managers absent, with the support of Mr and Mrs Clarke. The purpose of the visit was to review the requirements made at the previous visit and seek the views of both residents and staff. What the service does well: What has improved since the last inspection? The home has improved its approach in making the residents the centre of their care, their dreams, aspirations and goals and assisting the residents to produce their plan of care using in a tangible and realistic approach for the individual, and assisting the staff to see the residents for the person they are and not just the behaviour they present with. The inspectors viewed some very good plans and the residents with whom the inspectors met with were very excited and keen to share their plans and dreams. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 The home is working towards providing an environment where residents are officially made aware of their rights and the facilities available to them. The home demonstrates good practice in reassessing and attempting to meet the changing needs of the residents. EVIDENCE: At the time of the visit the requirement to produce a Service User Guide in an accessible format and ensure all residents have signed contracts had not been met. The inspectors were informed due to unforeseen circumstances regarding the absence of the manager there has been a delay in the production of an accessible Service User Guide. The inspectors informed the proprietors what had been agreed with the manager during the previous visit and a further tight timescale of three weeks to complete an accessible Service User Guide was made at the time of this visit. The proprietor was made aware that in the absence of the manager he must take responsibility for ensuring requirements are met within set timescales and must ensure that all residents receive a copy of the guide. At the last two visits to the home the proprietor was required to ensure all residents are issued with a contract stating terms and conditions of residency, which are either signed, by them or the residents representative. At the previous visit the manager stated she was keen to produce a contract that was accessible for the residents, however it was agreed within a very tight timescale that a formal contract would be issued and then work would start to make to ensure residents were made aware of the content of the contract. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 9 The inspector was provided with evidence that four contracts remain unsigned, the proprietors confirmed that there would not have been a problem sharing the contract with representatives and requesting them to sign them on behalf of the resident. A further requirement has been issued and the proprietors were informed that should there be a further failure to comply then enforcement action would be taken. The home demonstrates that they actively assess and reassess the changing needs of the residents in order to monitor if the home can effectively meet residents changing needs. The home seeks to undertake a multidisciplinary approach to ensure all aspects of residents’ health and welfare needs are appropriately monitored and reviewed. This was evidenced by the need to accommodate a resident on the ground floor as their changing physical needs now prevent them from using the stairs. Further review meetings are to be held in respect of the resident. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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 standard(s) 6,7, 9 and 10 The home provides an environment where the residents are involved as much as possible in planning, reviewing and making decisions about their care and supports needs. Risk assessments and supports plans are in place, however further work is required to detail, complete and review risk assessments for all residents. EVIDENCE: The home has demonstrated good practice in developing a person centred approach to meeting the care and support needs of the residents. The inspectors met with three residents who proudly shared their personal plans. The plans identified their strengths, support needs, daily routines, the important people in their lives, the things they like and dislike and their future plans. The residents stated that staff had helped them to complete their plans and there was evidence of residents signing and claiming ownership of them. The residents plans are currently held securely in the office, staff informed the inspector this was until a copy can be made of the plans, however the inspectors observed residents being encouraged to get their plans if they wished. The inspectors were shown two residents’ plans where staff played the Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 11 lead role in developing the plans due the residents limited cognitive function or their wish not to be involved. The plans demonstrated a very thorough and detailed approach to meeting the individuals needs using a person centred approach. In each plan seen by the inspector was a statement recorded by the resident stating if they were happy to share their plans with others in their absence. This is seen as very good practice and demonstrates the home respects the resident’s confidentiality and wishes. This was further demonstrated by staff who advised that one plan could not be seen by anyone else unless the resident was present. The inspectors saw written and signed confirmation of the statement made by the resident. The inspectors viewed three residents risk assessments and physical intervention plans, good work has been undertaken to identify the some of the key risks for each individual such as using stairs, using public transport and bathing etc, and how these can be minimised. However the proprietor in the absence of the manager must clearly document the physical intervention strategy used for each person and link them to a risk management plan, which clearly details what staff, need to do. The proprietor must also as far possible ensure physical intervention plans and risk management plans are signed by the residents’ or the residents representative. There is evidence in weekly staff meetings and supervision that the residents support plans and risk assessments are discussed, however evidence of discussions regarding one resident and the associated risks relating to the resident had not been updated or reflected in their personal plan. To ensure all staff are equipped with up to date changes of need and risks relating to individual residents the home must ensure that plans are reviewed and updated as required. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15 and 16 The home has undertaken some excellent work to develop the residents’ person centre plans, with the residents, which demonstrates that the home takes seriously its role to support residents in everyday valuing activities of their choice. EVIDENCE: The inspectors met with three residents and two staff who were very happy to share their person centred plans which they had produced themselves with the assistance of the staff. The residents talked through their plans, which included their daily routines, the things they like and don’t like, those who are important in their lives, the thing they like to do and their dreams for the future. The residents gave examples of the activities they are involved in such as community based activities such as shopping, going into town, peer group activities such as the” gateway” club and drama group, and holidays and leisure activities such as swimming, trampoling. Detailed in each resident’s plans are the dreams and aspirations each resident has, examples of this were to be a hovercraft driver and live independently. The inspectors observed positive engagement and relationships with staff. The staff gave assisted to the residents when it was requested such as reassurance or clarification about Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 13 what the resident had said. However the staff demonstrated a respectful approach in supporting the residents at the time of the visit. One resident with whom the inspectors spoke with was looking forward to his birthday and a trip on a hovercraft, his favoured activity, however the resident repeatedly stated he needed to remain calm for him to go on the trip. It could not be established at the time of the visit and from the resident why he needed to be calm. However the inspectors are aware the home uses CBT (Cognitive Behavioural Therapy) as an approach to assist residents to recognise and have an understanding of their thoughts, feelings and behaviours. A separate meeting has been arranged with the proprietor Mr Clarke to explore CBT further. In addition to the person centred plans the residents were keen show the inspectors their daily living skills, shared chores and their bedrooms. The residents stated they each had had daily living chores which they shared between them, which included washing up, tidying the kitchen and lounge, cooking the evening meal and preparing lunch boxes for the next day. Each resident appeared happy with the arrangements. There is evidence in personal plans that residents are supported to develop relationships with friends and maintain family relationships. One resident described how important it was to maintain those links. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The home clearly demonstrates that as far as feasibly possible it attempts to meet the physical and emotional health care needs of the residents. The home has safe systems in place support residents with their medication. EVIDENCE: The inspectors discussed at length with the proprietors and staff the current and changing health care needs of residents whose needs have changed significantly that the home has had to make adjustments to the resident’s environment and staffing levels. The home demonstrates that it has adopted a multidisciplinary approach to meeting the resident’s needs, including both primary and specialist health care teams, such as consultants, physiotherapists, GP and community nurses. The home has maintained close links with the relations and social worker. The home keeps good records of the resident’s daily activity and the support required to enable them to keep safe. The home has had to call upon additional staff to support the resident safely. Risk management plans and care plans are in place and there is evidence that the staff meet regularly to discuss the resident’s health care needs. The inspector wishes to be informed of the outcome of the next multidisciplinary meeting as the relocation of the resident to the office, although temporary, is unacceptable both for the resident and the home. The home has safe systems in place for the administration of medication, the home uses a dossett monitoring system supplied by a local pharmacist. There is evidence that staff are trained in administration of medication and the home Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 15 has developed clear protocols for “as required” medications (PRN), such as antipsychotic and anticonvulsant medications. The recommendation made at the previous visit regarding obtaining signatures from prescribing consultants and GPs was again discussed at length. The home must be able to demonstrate when there has been a change to residents’ medications; therefore this recommendation will be repeated. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home supports residents in an open and inclusive environment that enables them to express their concerns, however as with the Service User Guide the home must produce an accessible complaints brochure. The home as far as feasibly possible protects residents from abuse. EVIDENCE: Both the areas of complaints and protection were not fully visited on this occasion, however the inspectors saw examples of residents and staff positively engaging in conversation and activity. The residents were not aware of a complaints procedure but all the residents with whom the inspectors’ spoke with said they would go to a member of staff or the proprietors if they were unhappy. Discussion took place with staff on how they would support the residents who could not verbalise that they are unhappy or that something is bothering them. Two members of staff demonstrated active listening, a skilled approach used to support residents to express how they are feeling and support them to rationalise their thoughts. This approach is also used as an intervention strategy to support residents to remain in control of their behaviours. The home has a complaint procedure, however its current format is not accessible for the residents. The home is advised to develop a complaints procedure that is individually accessible for all residents, i.e. pictorial, audio, and provide information on who and how the resident can contact if they wish to make a complaint such as such as their care manager or the Commission for Social Care Inspection. Following a previous visit to the home the inspector misinterpreted how residents’ monies were held. The inspector believed the proprietor held and managed residents’ monies in one account in his name. The inspector Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 17 apologised at the time of the visit and would like to clarify on behalf of the proprietor that he has never held residents’ monies in a single account. Residents living at Ormsby Lodge have always had bank or building society account in their own name, although for a small number of residents the proprietor was the signatory. The proprietor is no longer the signatory on the residents’ accounts. Risk assessments are in place for those residents wishing to manage and hold their own money. The proprietor continues to access training for staff in a SCIPP r UK, a specific approach to supporting residents who have the potential to be challenging. Residents requiring this intervention have had the intervention agreed through a multidisciplinary approach. Staff demonstrated a very good understanding of their roles and responsibilities in ensuring the residents are supportive in this proactive and positive approach. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 25 and 30 The home provides a warm and welcoming environment for residents to live in, with adequate facilities in their rooms to meet their personal needs and interests. The home as far as feasibly possible protects residents from infection. EVIDENCE: The homes environment has been fully viewed and commented upon following previous visits and therefore was not fully viewed on this occasion, it provides a very clean and spacious environment to live. The residents with whom the inspectors met with were keen to show the inspector their bedrooms and proudly showed their possessions, which reflected their personalities and interests. One resident explained that he had recently moved to his room and he was very pleased with it. There was evidence that the resident takes pride in his personal belongings and bedroom. The room was very clean and tidy and the resident explained that he was supported to do this. Personal belongings demonstrated that the resident is actively involved in personal hobbies and interests and communal activities with his peers. The bedrooms are adequately furnished with quality furniture. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 19 Standard 30 was not fully visited on this occasion, however the staff could confirm that they hade received training in infection control and had all recently taking on an objective to research MRSA as part of their ongoing NVQ (National Vocational Award). Staff have access to gloves for carrying out personal care. The area of infection control will be fully viewed during the next visit to the home. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35 and 36 The home demonstrates that it takes seriously its responsibility to ensure the home has a well-supported qualified workforce to meet the needs of the residents. The home undertakes appropriate checks on new staff to safeguard the residents, however the home must ensure all references are credible. EVIDENCE: Following the previous visit to the home the proprietor was again required to ensure at least 50 of his workforce are trained in NVQ, this requirement has now been met, the home currently has eight staff trained to NVQ standards, two of which have undertaken level three and the manager who was undertaking her RMA (Registered Managers Award). The proprietors advised the inspector that they had applied to place the remaining staff on the NVQ starting September 2005. The proprietors are required to forward the names of those staff. The staff with which the inspector spoke with said they had found undertaking the NVQ a valuable experience. The inspectors viewed the homes recruitment procedures and viewed the documents of a newly employed member of staff. There was evidence to demonstrate that the home had undertaken all necessary checks and that the new member of staff had recieved a thorough induction into the home. However the requirement made at the previous inspection to check out the Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 21 credibility of references of a member of staff had not been met and the requirement was repeated. The home provides a comprehensive training programme for staff, which includes mandatory and service specific training. The home receives on ongoing basis training from Mr Clarke in SCIPP r UK, a specific intervention strategy to support residents who can be challenging. Staff with whom the inspectors spoke with were very clear about their role in using this form of intervention and demonstrated good values in the importance of knowing the person for who they are and not being blinded by their behaviours. Following a previous visit to the home the proprietors were required to ensure staff receive training in alternative communication methods. The staff discussed at length and demonstrated the alternative methods used in the home. The home uses a range of methods from Makaton, to using pictures and active listening. The inspector saw evidence in one resident’s plan of the specific communication method they use and how it links to specific behaviours and gestures i.e. “When I do this” “it means this” described in detail. The staff with whom the inspectors spoke with stated that staff are informed of different types of communication methods at staff meetings where each resident is discussed in turn, and where role play plays a big part in supporting staff to understand the residents method of communication. The inspectors were informed that it is compulsory for staff to attend meetings where peer and management support is provided. In addition the proprietor regularly meets with individual staff to discuss their work practices, any areas of concern and their training needs. The proprietors discussed at length the homes intentions to relook at the training package provided for staff, they have made application to become accredited trainers which will provide links to Learning Disability Award Framework, options to buy in external trainers and for the proprietor to work as an internal moderator with an external moderator for support. This is seen as a positive move to ensure staff are provided with accredited training. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 39 The proprietors ensure that there is competent staff in place to support the day-to-day management of the home. The home seeks the views of the residents however residents’ representatives and other professionals must form part of the quality review. EVIDENCE: Due to unforeseen circumstances the manager, the proprietors have nominated to become the registered manager has had to take long-term leave. The absent manager had demonstrated good knowledge and understanding of the legal requirements regarding registration and the group of residents she would be responsible for, however the application to register is on hold until such time a clear CRB (Criminal Record Bureau) has been received in the office of the Commission for Social Care Inspection. The proprietor has notified the Commission for Social Care Inspection of the homes temporary management arrangements and the inspectors met with the deputising manager who appeared confident and competent. The proprietor is advised to keep the Commission for Social Care Inspection updated on the situation with the Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 23 absent manager. The home has now developed an annual development plan and the home is in the process undertaking a quality review of the service. Through discussion the inspectors established that the home was taking the audit seriously, by meeting with and training staff and seeking support from BILD (The British Institute of Learning Disabilities). The proprietor stated that the process had started and the home was taking the audit seriously, by meeting with and training staff and seeking support from BILD (The British Institute of Learning Disabilities). Through the course of the visit the inspectors saw evidence in person centred plans of a quality questionnaire, which asked the residents views on the home the staff and their lifestyles this now needs to be extended to include relatives/representatives and other professionals involved in the residents lives. At the time of the visit the proprietors were required to forward to the Commission for Social Care Inspection a copy of the questionnaire to be used for relatives. The results of the quality questionnaire and its outcomes must form part of the annual development plan and forward to the Commission for Social Care Inspection by 31s August 2005. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 3 x 1 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x 3 x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ormsby Lodge Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x x H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 13(7) Requirement The registered person must ensure phyiscal intervention stratergies for all residents clearly details the interevention to be used. The registered person must ensure all identifed risks are completed on all residents and ensure the risk management plans reflect the current level of risk. The registered person must produce an accessible complaints procedure that is taylored to meet the individual needs of the residents. The registered person must ensure ithey obtain a further reference for the member of staff identified at the time of the previous inspection. This requirement has been repeated. A further failure to comply will result in further action being taken. The registered person must complete the quality audit and develop a plan of action based on the outcomes of quality audit. Timescale for action 31/08/05 2. YA9 13(4)(a) (b)(c) 31/08/05 3. YA22 22(2) 31/08/05 4. YA34 19(1)(c) 31/08/05 5. YA39 24(1)(a) (b)(2)(3) 18/07/05 Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 26 6. YA5 5(1)(b)(c) The registered person must 31/07/05 ensure all residents contracts are signed by the resident or residents representative as agreed at the previous inspection and by the agreed timescale made at this inspection. 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 YA20 Good Practice Recommendations The manager is advised to obtain copies of letters from psychiatrists when changes to service users PRN are made. I.e. Antipsychotic and Anticonvulsants. Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 Page 27 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton SO15 1GW 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 Ormsby Lodge H55-H03 S11717 ormsby lodge V218921 140605.doc Version 1.30 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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