Inspection on 18/05/07 for Orsett House Retirement Home

This inspection was carried out on 18th 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

Orsett House Retirement Home 12/07/06

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 18th May 2007 09:00 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.V339786.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.V339786.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 Mavis Toft 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.V339786.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 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.V339786.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on one day by one inspector. The Annual Quality Assurance Assessment (AQQA) was not returned to the commission by the required date, is a contravention of the Care Home Regulations and therefore does not form a basis for any information in this report. The Owners were on holiday but the inspection was carried out with assistance from the Registered Manager. As the AQAA was not returned it was not possible to obtain written feedback from any source. On the day on the inspection some time was spent talking to several visitors to the home who provided helpful and positive verbal feedback about the service. All visitors were regular, some visiting several times each week, the message was that the high standards are consistent. There were 47 people in residence, the majority of residents were seen and many spoken to. Those unable to verbally express a view were observed during the inspection. All staff on duty were seen and several spoken to. Good engagement and sensitive delivery of care was observed by staff during the inspection. Residents able to express a view on care provision were generally complimentary about staff care. Some viiews expressed are included in this report and include: early morning drinks and greater food choice. The physical environment was inspected with a sample of bedrooms. Records relating to the inspection process were all available as required in the home. Two residents from Polish and Indian cultures were reviewed. Staff were aware of the particular needs of these residents an example being a Polish person with severe dementia who lapses into her first language (Polish) on occasions – staff have learned some basic Polish language responses which they are able to use to reassure the person. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The Statement of Purpose/Service Users Guide are now readily available for residents/families/visitors in the reception areas of the home. The CSCI inspection reports and also now available in the home for all. The outcomes of the Quality Assurance surveys by the owners are now available in the home and also to the Commission. There has been a recent QA survey of visitors which has been included in the information available to all. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 7 The home have taken seriously and positively the suggestions for improvement and monitoring. Records required to be kept and available in the home for inspection under Schedule 4 of the Regulations were available for this inspection, in contrast to the unavailability of some records on the last inspection. There have been further ongoing improvements with redecoration and replacement of carpets etc. What they could do better: The protection of residents was found to be inadequate in a Vulnerable Adults situation since the last inspection. Lessons have been learned from this and discussions in staff meetings and additional training has been provided to ensure that everyone is aware of the standards and behaviours required of all staff. This needs to be monitored in the future. The night staffing numbers have reduced sometimes from 3 to 2 carers. This is not acceptable or safe. Three members of staff must be on duty at night time without exception. Agency staff must be used if necessary. Furnishings and equipment are to a high standard. A fraying carpet in the lounge area should be made safe and closely monitored. Improved recording and administration of PRN medication is needed. Preferred rising/retiring times should be recorded in care plans – there were 20 people having breakfast at the commencement of the inspection (8.30am.) and it was not possible to resolve the choice of rising times as they were not recorded. Residents said they would like a choice of hot dish at lunchtimes. In the main lounge area with chairs around the wall there were no tables between them to take drinks, food etc. Residents were served with hot drinks in their hands presenting the obvious risks. They had nowhere to put empty cups etc. – This was a recommendation of the last report. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 8 Female residents should be provided with personal care by a male member of staff only if they (or their family) have consented to it. – This was a recommendation of the last report. 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. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 9 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.V339786.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is good Pre admission procedures and documentation ensures good assessment of need There is adequate information to form a judgement about the suitability of the home for prospective residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: Requirements were made in the last 2 inspection reports to provide the Statement of Purpose/Service Users guide in the home. These are now readily available in the home, were inspected and seen to give comprehensive information about the home and the services provided. At the time of the last inspection a relative had commented that inspection reports were not available in the home. These are now provided and were readily available in the reception areas. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 11 Contracts were seen for self-funding and funded residents and were satisfactory. People moving into the home are seen and assessed prior to admission by the homes staff. In two records seen of recently admitted residents there was a comprehensive pre-admission assessment available and a Care Management assessment was also provided. This ensures that needs are assessed and can be met by the home. Where possible visits to the home by prospective residents are arranged, a person recently transferred from a Local Authority home had made a preadmission visit to Orsett House. Intermediate care is not provided in this home. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. Health & Personal care needs of residents are clearly defined and met. Medication records are generally well maintained. Attention to details of PRN medication is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were sampled including those of recently admitted and also long-term residents. There is a good care planning information format providing quite adequate information to provide care based upon assessed needs. Plans are reviewed monthly in the home. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 13 Records showed adequate information on all aspects of health, personal and social care needs. There are 3 daily entries for each person matching the staff shift patterns of the home. A requirement of the last report to provide evidence of consents from residents/relatives to personal care from male staff have not been obtained for new or existing residents. The Manager, present on this visit, said this would be provided. A recommendation to record rising/retiring times in care plans had similarly not been provided. The Manager intends to include this information. A further recommendation in this report to provide early morning drinks for residents should also be detailed in this information. Health care information was well recorded. Nutritional needs are recorded and residents weighed monthly where physically possible. All residents have recently had revised assessments by the Continence Advisor. There are no tissue viability needs in the home at this time, one person is provided with an alternating pressure-relieving mattress supplied by the Nursing Service but skin is intact, this person has been virtually bedfast for 2 years. In fact the nursing service are not visiting the home at this time and there are no tissue viability issues. Several residents are physically frail often due to physical deterioration as a result of Alzehimers Disease. The care of a frail 102 year lady was reviewed and found to be to a very high standard. There was detailed information about nutritional and tissue integrity, moving & handling and all aspects of other personal care. The resident was seen to be able to express her needs to staff very positively. A large proportion of residents have dementia care needs. Several are able to wander as they wish in the home, others have high dependency needs and cared for in a separate area. Staff were seen to provide care to this group in a sensitive and caring way providing individual care in a person-centred way. Observations at lunch time showed staff assisting with feeding on an individual basis with no timescales and responding to the immediate demands of other residents with care and consideration. A good service was reported by the GP practice at nearby Barlaston Health Centre. A GP visited during the inspection at the specific request of a resident who needs constant confirmation/reassurance about her physical care. The medication system was inspected. Records generally were accurate and well-kept. An exception was Diazepam prescribed PRN which was hand-written on the MAR sheet and the blister-pack stated “as directed by your doctor”. To clarify the instructions for the PRN use it was necessary to refer to a daily note entry some 2 years previously when the medication was originally prescribed. When this medication is given (recently fairly often) daily notes stated the person had been “aggressive” – this information is inadequate and nonspecific. It is important that records are updated with printed instructions on Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 14 the MAR sheets and detailed recording of the circumstances under which the medication is given. All staff administering medication have received appropriate training. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. Daily life and activities are sufficient to cater for the needs of most residents. People with dementia care needs have personal/individual interventions to meet their needs. Contacts with family/friends are encouraged and promoted. Choice should be extended to main meal food choice for all residents. Early morning drinks are requested by residents and should be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a weekly activities programme with daily record of activities provided. Entertainers visit the home seemingly monthly which residents said they enjoyed. The social needs of residents are diverse. Several residents choose to wander in the home which they do safely. – There have been no recorded accidents in the past year. There is an excellent large enclosed garden area with lawns, flowerbeds and a summer-house which is used throughout the summer. All residents enjoy this good facility. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 16 Some are in the advanced stages of dementia and highly dependent. There is a staff concentration for those people. The importance of 1:1 engagement is vital for many residents, some unable to partake in any group-type activities. Throughout the inspection there were several instances of noted good individual staff engagement with residents, both during the quieter times of the day and also when care was given e.g. positive encouragement and stimulation when being assisted with feeding. A smaller group of less dependent residents were able to express their views about their life and expectations in the home. They were able to communicate freely with other residents of their choice or staff. Some enjoyed reading others just talking together. Although available, TV was not used generally during the day, background music provided a more relaxed atmosphere in all parts of the home. Residents able to express a view were generally satisfied with the care provided. Two issues were raised by them: Early morning drinks are not provided – residents had been assisted to rise by night care staff and were sitting in the lounge at 9.15 awaiting breakfast but had not had a drink. They would like this and it should be provided. Residents said that there was no choice of main dish at lunchtime (this was confirmed by displayed menus). People clearly had to ask for alternatives if they did not like the prepared meal and of course this does not happen. Main meal choices must be offered to residents. Clergy visit the home monthly and provide communion service for those choosing to attend. Roman Catholic priest visits also from Stone. Several visitors were seen arriving throughout the morning (4 couples). All were spoken with, were very relaxed and were regular weekly visitors (some several times per week). All interacted with each other, staff and the inspector as they arrived. All spoke highly of the home and staff care, giving examples of progress and the high satisfaction with standards of care. One of the visitors still visits although his relative has died – he visits other residents and spoke highly of staff care. Orsett House Retirement Home DS0000004988.V339786.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The complaints procedure is clear and readily accessible to all. There is evidence that service users were not protected from abuse in a recent vulnerable adults referral. Action has been taken to remedy this and ensure staff are aware that such behaviours are unacceptable and will not be tolerated. The past history of improvements and compliance of the provider indicate this will be the case. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is satisfactory and clear. Copies are posted in the home and available in the Statement of Purpose/Service Users Guide. There have been no complaints made directly to the home over the past year. A referral has been received from an external source since the last inspection relatling to the abuse of a resident by a member of staff. This was dealt with under the Adult Protection Procedures. The incident had been known to the Proprietor and Manager prior to the referral who had not taken the required action. The incident was serious and ultimately the member of staff dismissed. The providers had been slow to take action to protect residents. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 18 This incident was 12 months ago and since that time the Provider and Manager have had the opportunity to retrospectively consider their responses. They understand that instances of this nature must be dealt with immediately, firmly and to protect the interests of residents. The issues have been discussed at staff meetings indicating that such actions were not acceptable and would not be tolerated in the future. Although all staff had received training in the Protection of Vulnerable Adults prior to the incident, further training was recently arranged for staff in this area to ensure clarity about staff roles and the actions which must be taken where there is suspected abuse. The indications are that that lessons have been learned and actions taken to ensure future protection of residents. The provider has not reported this matter for inclusion on the POVA (Protection of Vulnerable Adults) list and this must be done. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. A high standard well-maintained environment with good facilities and access. Bedrooms and facilities suit residents needs in comfortable, clean and pleasant surroundings. Attention is needed to fraying carpet and provision of tables in lounge areas only. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a good standard environment which meets the National Minimum Standards. The home has been in the present ownership for the past 20 years and improvements and re-investment made during that time. Maintenance is good and the standards of décor and furnishings are maintained with ongoing improvement plans. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 20 All bedroom with the exception of 2 have en-suite facilities. A sample of bedrooms seen indicated that they were well-furnished and equipped and had been personalised to reflect the individuality of residents. Additionally there are 5 bathrooms and shower room (all assisted) located throughout the home. All areas inspected were clean and hygienic and odour control management was good, even in areas where there are particular known difficulties. There are 4 separate lounge areas throughout the home some with recessed areas allowing small group seating. There is a large dining area which is pleasant, spacious, bright with good décor. A recommendation of the last report has not been actioned. This was to provide tables between the chairs in the main lounge areas to accommodate drinks etc. People had been given hot drinks by staff whilst seated and had nowhere to put the full/empty cup and presented a potential hazard with hot drinks. This recommendation is repeated in this report. Some lounge chairs are older and marked and the Manager said that replacements were planned. In a lounge area a carpet had frayed near to the sitting area presenting a “loop” which was a potential trip-hazard. This must be made safe immediately. The need to allow some residents with dementia the facility to wander within the home is good, with wide corridors, level access to internal and external areas but protected areas where there may be a hazard (external doors are alarmed etc) The external garden/patio/seating area is excellent. It is safe, pleasant, has comfortable seating and allows residents and visitors to walk or sit safely. There is a summer-house with good seating etc. This is a central garden/courtyard area central to the home which allows monitoring of people using the area. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is adequate Staffing levels are generally satisfactory but the numbers of night staff must be consistent to ensure safety for residents This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection some records relating to staffing and other matters were not available in the home as the provider and manager were on holiday. A requirement was made to ensure all records are available in the home at all times. This has been done. Although the provider was on holiday records mentioned above had been made available at all times both for senior staff and inspectors. The staffing rotas were seen. The staffing level in the home is 7:5:3 (throughout the 3 shifts of each 24 hour period). This staffing level is needed and is adequate for the perceived dependency levels of residents. Rotas seen showed that recently, due to staffing shortages there were sometimes only 2 staff on duty throughout the night. It is important that 3 staff are consistently employed at night time – there are 47 people in residence, some have high dependency needs and the geography of the Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 22 building does not allow easy monitoring. It is unsafe to employ less than 3 people throughout the night. This number would be inadequate in an emergency. A sample of staff files were inspected and contained required information and checks prior to employment including POVA/CRB checks and other documents required under Schedule 2. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. The home is well managed and run in the interests of residents. The health, safety and welfare of residents are generally promoted. It is felt that safety issues raised in this report in relation to staffing, environment and protection will be addressed by the providers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has worked at the home for many years. She has the required experience and qualifications to run the home. There is a close working relationship with the owners of the home, one is a joint Registered Manager. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 24 The Manager showed knowledge and competence throughout the inspection having details knowledge of the needs of residents and showing a positive working relationship with staff. She is well known to visitors and has a very relaxed, open positive engagement with them. There have been 2 previous requirements for the outcome of quality assurance surveys to be available in the home and open to scrutiny by visitors and other stakeholders. This has now been done. In fact the results of a recent quality audit of relatives and families was carried out in March 2007 were available and seen during the inspection. It was positive to see that the comments made had been acted upon in a very positive way, the home feeling that any concerns or criticism should be taken seriously and addressed. This had been done and some changes made. There have been no notifications of accidents under Regulation 37 in the past 2 years. The accident book and records were checked and this was quite correct. Risk assessments are in place as required and the outcome appears to be a safe environment. This is particularly positive as many residents with the earlier stages of dementia who have mobility are clearly safe to wander as they wish. Finances are not held on behalf of residents by the home, they are assisted by relatives/friends as needed. Records relating to the financial viability of the home were not seen but the good standard and well maintained environment indicate good financial status. Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 26 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. 2. 3. 4. Standard OP18 OP27 OP9 OP19 Regulation CSA 82(2)(a) 18(1)(a) 13(2) 13(4)(a) Requirement Referral must be made to POVA list for person dismissed Required & agreed night staffing levels must be sustained at all times Instructions and reasons for PRN medication must be clearly recorded Carpet in lounge area must be made safe. Timescale for action 30/06/07 31/05/07 31/05/07 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that rising/retiring times for residents 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.V339786.R01.S.doc Version 5.2 Page 27 3 4 5 OP15 OP15 OP10 Main meal choices must be offered to all residents All residents should be offered early morning drinks after waking Female residents must consent to personal care from male staff Orsett House Retirement Home DS0000004988.V339786.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Local Office Dyson Court Staffordshire Technology Park Beaconside STAFFORD ST18 0ES 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. 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