Inspection on 12/07/06 for Orsett House Retirement Home

This inspection was carried out on 12th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Orsett House Retirement Home 18/05/07

Orsett House Retirement Home 26/09/05

Orsett House Retirement Home 14/04/05

Orsett House Retirement Home 23/11/04

Orsett House Retirement Home 17/08/04

Orsett House Retirement Home 14/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Orsett House Retirement Home Station Road Barlaston Stoke On Trent Staffordshire ST12 9DQ Lead Inspector Peter Dawson Key Unannounced Inspection 12 July 2006 08:30 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 Orsett House Retirement Home DS0000004988.V304008.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. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orsett House Retirement Home Address Station Road Barlaston Stoke On Trent Staffordshire ST12 9DQ 01782 372147 01782 374336 cozier@orsetthouse.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Frederick Cozier Mrs Coral Cozier Care Home 49 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (49), of places Physical disability over 65 years of age (15) Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 September 2005 Brief Description of the Service: Orsett House is a care home providing care and support for up to 49 older people. Of that number the Home can provide services to 32 people with dementia care needs and 15 with a physical disability. Orsett House is large Victorian style property, situated in the village of Barlaston, Stone, Staffordshire. It has been considerably extended over the years and provides a good quality environment set in extensive attractive gardens with patio areas, summerhouse and peaceful gardens. Access from the house is good with ramped areas and handrails providing a safe garden area. The Home is separated into two units; one of which supports the residents with dementia care needs and has a higher staffing ratio and the other, in which a less dependent group reside. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the inspector’s first visit to this home. The Proprietor and Manager were on leave and the inspection was carried out with assistance from the Assistant Manger on duty. A pre-inspection questionnaire was received from the proprietors. Fourteen residents and three relatives provided written feedback direct to the Commission. All communal areas were inspected and a sample of bedrooms. Records relating the inspection process were seen with some restrictions due to unavailability of some records. All residents were seen and the majority spoken to. All expressed high levels of satisfaction with the care provided and spoke highly of staff care and commitment. These matters were observed during the inspection and there was extremely good dialogue noted between residents and staff. This applied to all residents including those with high dependency needs some having little or no speech. It was clear to read the non-verbal responses from those residents. Written feedback was received from 14 residents and 3 relatives. All made very positive comments about the home and the care provided. Residents comments included: “I think everyone is marvellous it is a very nice place to live” “I don’t like joining in (activities) I prefer my own company, but there is plenty to eat and I am quite happy here”. “I was very unhappy in another home. This is the best home I have been in and I am happy, I get good attention” “staff are very good and kind”. Equally complimentary written comments were received from relatives including comments: “Orsett House is looking after mum very very well”. All the communal and garden areas of the home were inspected and also a sample of bedrooms. All were bright, clean and well furnished. There is an abundance of natural light throughout the home. Many communal areas have recently been redecorated. All staff on duty were spoken to and were relaxed and helpful during the inspection. All were quite approachable and discussed daily life in the home in a very open way. Staff training was reported to be readily available and staff felt able to approach managers or proprietor with any concerns they may have. Staff clearly enjoyed their work evidenced by their interactions observed with residents and the information they gave during the inspection. Although the inspector has not visited the home previously the impression gained is: A good home with evidenced good care provided in a high standard and well maintained environment. Staff are very relaxed and committed. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 6 The weekly fees payable in this home are £385. This information was given in the Pre-inspection questionnaire. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose/Service Users Guide is still not available in the home for current and prospective residents and relatives. A further requirement is made. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 7 A copy of the last inspection report must be similarly available to all residents, visitors and staff. Outcomes recording the results of the Quality Assurance surveys by the home must also be available. The unannounced inspection was limited by the unavailability of some records which are required to be available in the home at all times. Staff temporarily managing the home may also require this information. Consents must be obtained from all residents/relatives for personal care to be provided for female residents by male carers. It is recommended that rising/retiring times are recorded in care plans as a guide to ensure there is no confusion about them. It is recommended that in the main lounge area small tables are provided between seats to allow safe and convenient service of drinks etc. 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. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The quality of this outcome is adequate. This judgement is made using available evidence including a visit to the service. EVIDENCE: A requirement of the last report to provide the Statement of Purpose/Service Users Guide has not been actioned. On this visit the Proprietor and Manager were on holiday and the SOP/SUG were not available in the home. This must be provided and readily available in the reception/communal areas of the home for current and prospective residents and visitors. A coy of the last inspection report was similarly not available and must be made available to all. A relative in written feedback had indicated reports were not available in the home. It appeared that all residents were seen in their current environment prior to admission and an assessment carried out by the home. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 10 Due to the absence of the Proprietor/Manager mentioned above the homes pre-admission assessments were not available and it was not possible to ascertain whether residents were funded or self-funding and whether a Care Management Assessment had been made. This information was available only to the Propeitor/Manager. Several new residents were spoken to and indicated that they had been assisted by staff to settle well into the home. It appeared that conscious choices had been made and pre-admission visits to the home had been made. One person said that she had a previous respite care placement at Orsett House but when the decision for permanent care became apparent, she had visited other homes but ultimately chosen Orsett House. She was very complimentary about the care provided, how visitors were welcomed at any time and although this was her preferred choice of home she still had misgivings about the decision for permanent care. Staff confirmed that they were aware of this and were clearly supporting the resident during this difficult period of adjustment for her. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 The quality of this outcome is good. This judgement is made using available evidence, including a visit to the service. EVIDENCE: Care plans were sampled and 3 were tracked. Information was generally comprehensive, good and relevant. The care planning format is suitable for the resident group and provides generally adequate information. There were some gaps in monthly reviews on a record seen and in relation to a longstanding resident now with very high dependency needs it was agreed that the amended plan should be replaced by a re-written current plan of care. Other records seen provided quite adequate information on all aspects of health and social care needs. Care records contain 3 daily entries for each person reflecting the staff shift patterns of the home. In relation to a recent admission the short term care plan was well written. There were comments in the daily notes about her being “agitated when put to bed” .” Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 12 The preferred rising/retiring times were not included in care plans, and although this may obviously vary/change it is recommended that this information is included providing a basic guide. Health care information is well recorded. Several residents in the advanced stages of dementia are quite high dependency, some requiring total care. There were clear instructions for staff concerning the actions required to provide this care including eating, turning, seating, posture and all personal care requirements. Two residents have grade 1 (Sterling) pressure area sores seen several times each week by the Nursing Service and staff following instructions for moving and seating. Both have alternating pressure-relieving mattresses and appropriate specialist chairs. Other residents without pressure area sores are provided with overlays/cushions and several have specialist chairs for positioning and safety. The high dependency resident group in the main area of the home have additional staffing to meet those needs. Many have to be fed or need varying degrees of assistance/oversight with feeding. Sensitive, individual feeding was observed during mealtimes. Nutritional needs are catered for exceptionally well. All residents spoken to were extremely complimentary about the quality and quantity of food and the choices available at all mealtimes were good. Catering staff are aware and have a list of all specialist food needs, these were available for all and included recently admitted residents. All residents eat well and the importance of good nutritional care understood by all staff. Fresh fruit is given to all residents each day. The importance of fluid intake is understood. All residents including the two with pressure area sores have good diets, eat and drink well and there is no need for fluid or food intake charts. One resident has lost weight recently and referred to the GP who is investigating – this residents continues to eat and drink well, her habits have not changed. All residents are weighed on at least a monthly basis. Some residents in the advanced stages of dementia have little or no speech but staff were seen to attempt to engage in ongoing contacts with them by means of verbal and other means of communication. Some residednts expressed their responses simply with smiles. This was evidence of good engagement with residents. The home is serviced by a reported good service from the 5 GP’s operating from the Barlaston Health Centre. The District Nurses operating from that centre also provide a good service, visiting only at this time in relation to the 2 residents requiring pressure area. Areas of health care concern can be readily discussed with GP’s/District Nurses. Medication records and the Blister-pack (MDS) system of administration were inspected. All records including MAR sheets had been correctly completed an signed by staff. Incoming medication is checked by staff before being placed into the system and all returns to the pharmacy are listed and countersigned. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 13 The evidence indicated a safe system of medication in place. In relation to privacy/dignity, a requirement is made to seek consents from residents or relatives for personal care being provided by male staff to female residents. In relation to death and dying, care planning information recorded the wishes and instructions of residents in the event of death. A card was seen from relatives of a recently deceased resident thanking staff for the care provided to their relative and to the family at that difficult time for them. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The quality of this outcome is good. This judgement is made using available evidence, including a visit to the service. EVIDENCE: Residents able to express a view said that their choices and preferred lifestyles were known and acted upon. The indications were that staff routines were geared to resident need. Rising/retiring times are referred to previously in this report and should be recorded and known. A resident in the lounge area had been bathed and hair set in rollers by staff which she said was her preferred day, time and routine. Virtually all residents were having breakfast in the dining room when the inspection commenced at 8.40a.m Night staff (finishing at 8 a.m.) had clearly been involved in the rising, washing and dressing of residents. Staff reassured that early rising was the residents preferred options. This was confirmed in later discussions with residents able to express a view. Again - the recording of preferred rising times would further confirm peoples individual preferences. There was no reason to believe that people had been woken or rushed to the breakfast table. One resident did say that he had risen at 4 a.m. which was usual for him, he had come downstairs had tea and a cigarette as he wished. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 15 The range of activities is reported to be: Progressive mobility (monthly). Reminiscence, singalongs, quizzes, bingo, newspaper reading/discussion, library (several read books). Staff read to the more dependent residents. One registered blind confirmed that staff do read to him – he has previously declined talking books/newspapers. In relation to very dependent residents unable to join activities staff spend 1:1 time with them. (this was seen and confirmed during the inspection.) The annexe contains 15 people of lower dependency – those not suffering from dementia or in the very early stages of it. There was an excellent atmosphere residents moving freely around and socialising. Much good humoured bantering was observed between residents and with staff. A 101 year old man (looking and acting like a 70 year old) confirmed he had good health, certainly had total control of his faculties said that he had been at the home for 2 years and was entirely satisfied with the care and facilities provided for him. He goes to the local shop daily to collect his newspaper and other items for residents unable to go out themselves. He spoke in a relaxed and confident manner about “spending the rest of his days” at Orsett House. He was flirtatious with staff who responded in a humorous and acceptable professional way - all residents clearly enjoying the banter and the resident the attention it brought. There was a very relaxed atmosphere throughout the home, staff readily engaged in conversation with residents, visitors and the inspector. In the lounge areas accommodating very dependent residents background music was playing throughout the morning, rather then the compulsory TV viewing for all. Questionnaires received from relatives directly to the Commission indicated that visitors were welcomed into the home and all were satisfied with overall care. Comments included “Orsett House is looking after mum very well”. A resident registered blind who does not have visitors says he is taken to the shops each week by staff. He smokes regularly and being unable to smoke in the home he uses the patio adjoining the lounge area which reduces any inherent risks (there is a risk assessment). He is happy with these arrangements. He contrasted the care at Orsett House with a previous long term unpleasant experience in another home. As reported previously all residents in feedback and conversation on the day confirmed their high levels of satisfaction with the food provided. There is no doubt that nutrition is high on the care agenda. The dining room in the main area is bright well decorated with well- laid tables. The smaller dining area off the annexe in the lounge provides equally good environment resembling a domestic dining area. One area of concern was in the most used of the 3 lounge areas in the main building, where mid-morning tea was served to about 12 residents. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 16 There are no small tables between the seats which are placed around the perimeter of the room. Tea was given to residents to hold and drink with a risk of spillage. When drank cups had to be held or in some instances were placed on the seat of their chair. It is recommended that small tables are placed between chairs in this room to hold drinks and other personal effects if required. In fact cold drinks could be constantly available to encourage fluid intake particularly in hot weather. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 - 18 The quality of this outcome is good This judgement is made using available evidence, including a visit to the service. EVIDENCE: There is a complaints procedure posted prominently in the home which is quite satisfactory and meets the requirements of Regulation 22. This is readily available to all residents and visitors. The Assistant Manager reported that no complaints had been made to the home to her knowledge since the last inspection. It was not possible to see the complaints records which were locked away in the absence of the proprietor/manager. No complaints have been received by the Commission. 14 questionnaires from residents were returned to the Commssioin prior to the inspection. Without exception no had any complaints. All indicated that they were aware of the procedure for making complaints – the answer to the question “ Do you know who to speak to if you are not happy?” was either “speak to my family” or “Mavis” (Manager). Staff have received training in the Protection of Vulnerable Adults. The numbers not known as staff training records were not available. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 The quality of this outcome is good. This judgement is made using available evidence including a visit to the service. EVIDENCE: There is a good standard environment in this home. The communal areas were all bright and many have recently been redecorated. The standards of furniture, fittings and equipment are good. Some of the chairs in the lounge in the main areas would benefit from upgrading, but generally furnishings are to a high standard and well maintained. The communal and bedroom areas all have large windows allowing plenty of natural light. A sample of bedrooms were seen and the standards of furnishings and décor were good. All contained the required furniture and fittings to meet the National Minimum Standards with good personalisation. All bedrooms are en-suite with the exception of two which have toilet areas located close by and have commodes. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 19 Only one bedroom is shared at this time and there was screening in place to ensure required privacy. There are 4 bathroom areas throughout the home including one walk-in shower area. All are assisted. Due to their dementia care needs, many residents need to wander within the home. This is facilitated with wide corridors on one level and access to stairs and external doors appropriately inaccessible to ensure a safe environment. All external doors are alarmed and some work advised by the Fire Officer was carried out last year to ensure complete safety for these and all residents. The interior of the home gives the impression on a well appointed and well maintained environment domestic in type. The exterior of the home is equally good and quite exceptional The grounds extend to around 0.5 acres. There is a central patio area accessible from most points of the “U” shaped building. There is good seating with tables and umbrella shades making an attractive focal point. The large summerhouse is just being refurnished but easily accessible and provides an attractive area surrounded by lawned and well-kept garden areas. There are ramps and handrails to ensure good and safe access for wheelchairs and residents and visitors wishing to walk in the grounds. The area was certainly being well-used on the hot day of this inspection and residents reported they enjoyed the garden area throughout the summer months. The area is private and secluded. The standards of hygiene throughout the home are high and although there is a very high incidence of incontinence (35 singly incontinent and 15 doubly incontinent) odour management is well controlled with aggressive cleaning routines which were outlined by the domestic assistant on duty. Continence and clinical waste are daily removed from all areas. Some bedrooms have been fitted with non-slip vinyl flooring where continence management is particularly difficult. The laundry was not inspected on this visit. All bathroom and toilet areas were clean and hygienic with good hand-washing facilities throughout and soap/paper towel dispensers in crucial areas. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The quality of this outcome is adequate. This judgement was made using available evidence including a visit to the service. EVIDENCE: It was not possible to have access to the staffing rotas on this visit due to absence of proprietor/manager. The only rota available was for the current week (2 days) and there was an omission for one of those days. Staff files and staff training records were not similarly available. These factors restricted aspects of staffing which could be inspected. The staffing level of the home appears to be 7:7:3 (the afternoon shift reducing to 6 staff from 4 pm. Staff are allocated to the main building and annexe separately, although there is flexibility of movement as required between the units. This level of staffing was evident on the day of the inspection and appeared adequate for the perceived needs of the current resident group. There are 2 Assistant Managers, and 7 Senior Care Workers. There is a Senior member of staff on duty throughout the 24 hour period. Staff on duty were all spoken to and the inspector was impressed with their relaxed and open approach to residents, each other, visitors and in assisting with the inspection process. Staff were seen providing personal care to very dependent residents in a sensitive, caring and professional way. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 21 There was excellent banter and friendly and humorous exchanges between staff and the less dependent residents. A very good, relaxed and positive atmosphere was evident. Residents clearly felt comfortable, relaxed and were quite open in discussions with staff present. Staff competency was evident. At the time of the last inspection one third of staff had obtained NVQ2 status. The current numbers were not known and the target must be 50 . NVQ training is reported to have continued since the last inspection. NVQ training is also offered to catering and domestic staff. It was reported that planned courses in food hygiene, medication and the Protection of Vulnerable adults (per the last report) have taken place. Also certificates were seen relating to a course on Dementia Care needs which several staff attended. There are 3 moving & handling approved trainers in the home, adequate to ensure all staff receive this training. The inspection of recruitment procedures was not possible on this visit, as staff files were not available. Staff changes have been minimal over the past year. There are currently no vacancies. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36,37,38 The quality of this outcome is adequate. This judgement was made using available evidence including a visit to the service. EVIDENCE: This is the inspectors first visit to this home. The Proprietor and Manager were both on holiday and therefore not known. It is therefore not possible to make a judgement about the Management of the home. The inspection was carried out with the Assistant Manager Dawn Bridgett who assisted in all aspects of the inspection. Her detailed knowledge of the home was excellent and apart from some documentation which was not available she was able to provide all the necessary information required for the inspection. She has good communication skills and is clearly more than competent to manage the home as required. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 23 Regular staff meetings and supervision of staff is in place. The home does not manage finances of behalf of residents. Therefore financial procedures were not inspected. At the time of the last inspection the proprietor had carried out a comprehensive quality review with questionnaires from relatives and families. The information was to be made available to residents/relatives but was not available on this visit. This should be included in the Service Users Guide. Records seen were generally clear, concise and to a good professional standard. Care planning information is based upon a good recording system which suits the purpose of the home. Only minor additions/changes are required to care plans. Care planning information was good and provided the necessary information to provide care. Records not available due to absence of proprietor/manager were: Staffing rosters, accident records, complaints records, staff training records and quality assurance information. These should all be available in the home at all times as required under Regulation 17 and the proprietor should consider ways ensuring this information is always available. The proprietor provided the Commission with a list of the homes Health & Safety maintenance and associated records prior to the inspection which was checked and satisfactory. Fire records were inspected and all checks and servicing of equipment had taken place. The Commission had not received any notifications of accidents to residents since the last inspection (11 months). It was not possible to check this against the accident records, which were not available. The Assistant Manager said that as far as she could remember there had not been any notifiable accidents during that time. If this is correct it is an excellent record considering the high dependency levels of some of the residents, many of whom have a propensity to wander. A safe environment is evident in the home. Orsett House Retirement Home DS0000004988.V304008.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 2 x 2 2 2 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x 3 2 3 Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 (2) 5(2) Requirement Timescale for action 31/07/06 2. OP33 24 (2) Potential and existing residents and/or their families should be made aware of the availability of The Statement of Purpose and Service Users’ Guide to ensure that they have access to the fullest information regarding the service provided in Orsett House. Timescale not met. A collation of the quality 31/07/06 assurance results must be available to the residents and the Commission for Social Care Inspection. Timescale not met Records specified in Schedule 4 must be available for inspection at all times. Obtain consents from residents or relatives for personal care provision by male staff A copy of the last inspection report must be available in the home to residents and visitors 13/07/06 13/07/06 31/07/06 3 4 5 OP37 OP10 OP1 17(3)(b) 12(4) 5(1) Orsett House Retirement Home DS0000004988.V304008.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 2 Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that rising/retiring times for esdients are included in care plans It is recommended that tables are provided between seats in the main lounge area to accommodate drinks etc. Orsett House Retirement Home DS0000004988.V304008.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Orsett House Retirement Home DS0000004988.V304008.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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