Inspection on 26/09/05 for Orsett House Retirement Home

This inspection was carried out on 26th September 2005.

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 18/05/07

Orsett House Retirement Home 12/07/06

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

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Aston Court Nursing Home

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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 Sue Jordan Announced Inspection 26th September 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 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.V253568.R01.S.doc Version 5.0 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 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.V253568.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th April 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. 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.V253568.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place over six and a half hours. An Announced Inspection was planned so that the proprietor could ensure that the staff records were available, as a number of deficiencies had previously been identified. The methodologies used were scrutiny of the pre-inspection information provided by the proprietor and the fourteen questionnaires completed by some of the residents and some family members. Informal discussions were held with some of the residents and three staff members and more formal consultation with the proprietor and the manager. Lunch was shared with the residents in the annex area of the Home. Staff files, care records and some Health and Safety records were also checked. What the service does well: What has improved since the last inspection? Since the last inspection the Fire Safety Officer has inspected the Home and a number of requirements were made. The proprietor was able to demonstrate that all of the issues have been addressed. One of the most important areas addressed is maintaining the safety and security for those residents with dementia care needs, whilst adhering to fire safety legislation. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 6 Three staff files were checked and all now contained the required elements. The staff training files have been re-organised and training opportunities have been expanded. The management team is now better able to monitor that staff are receiving the compulsory training at the correct frequencies. Deficiencies have been identified and appropriate courses planned. The proprietor is looking for a more in-depth training course on the subject of dementia care needs. The activities programme continues to improve and innovative ideas were observed. 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. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 The 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. EVIDENCE: The Statement of Purpose and Service Users’ Guide have both been updated. However service users and/or their family’s accessibility to these documents was discussed during this visit. The proprietor and manager agreed to look into ways of making people aware of their availability. The assessments were checked in detail at the last inspection and found to meet the requirements. It was noted during this visit that the Home had received a Local Authority Care Management assessment and care plan for a resident in receipt of respite care. Self-funding residents have a contract with Orsett House. Orsett House does not provide intermediate care. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 9 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, 8, 10 Personal and health care needs are identified in the care records and are, as a result monitored and reviewed. EVIDENCE: The care records continue to be completed comprehensively. Records for two residents were checked and they contain clear information and guidance for staff, including individual assessments of risk. The care plans seen were reviewed monthly. Seven questionnaires were completed by service user families and received by the Commission for Social Care Inspection. All said that they were satisfied with the overall care provided in the Home. Additional comments included, “my husband appreciates the way her personal dignity is respected”, “I am very pleased with the help and care my Mum is receiving” and “we are very pleased with the care and attention given”. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 10 One of the residents explained that he had lived in three care homes and that Orsett House was the best. His main reason for this was the privacy afforded by having his own bedroom and en-suite toilet. There is evidence throughout the care records that medical health professionals are consulted and accessed for the residents. The weight of the residents is well monitored. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 11 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, 13, 14, 15 Visitors are made welcome in the Home and efforts are made to provide the residents with activities and stimulation. EVIDENCE: The activities programme continues to develop and one of the staff spoken to explained the activities presently being provided in the Home. She is responsible for organising these and expressed an enthusiasm and commitment for developing new ideas. These have included producing a witty newsletter, a topical news board and organising games and quizzes. With the advent of the Christmas period, she has plans to make Christmas decorations etc. The difficulty of organising activities for the service users with dementia care needs was discussed. This may be helped when the owner is able to access suitable dementia training. On the day of this visit, an organist came into the Home to entertain some of the residents and another went for a walk to the local shop, accompanied by a member of staff. Another resident takes a daily walk to the shop to fetch a newspaper. The questionnaires completed by the residents’ families and received by the Commission for Social Care Inspection all stated that the staff and owners welcome them into the Home. Additional comments included, “everyone is very Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 12 friendly here” and “we have always found all staff to be caring and friendly and approachable. The Home is very welcoming to all”. The people living in the annex area of the Home are invited to attend residents’ meetings. Menus are written on a board on the wall and they are going to help produce the next newsletter. The annex area has it’s own small kitchen area for making drinks and snacks and some of the residents occasionally help with washing the dishes. A choice of deserts is available at lunchtime and alternatives offered at teatime. Lunch was shared with the residents in the annex area. All of those spoken to expressed their satisfaction with the food provided. The meals are dished out from a trolley and as such this means that they are able to choose the quantities and whether they want all that is on offer. Two dates have been organised for staff to receive food and hygiene training. The member of staff in the annex was observed using a food temperature probe. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 13 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 approachability of the staff and manager ensure that the residents and/or their families feel able to discuss their concerns. Improved staff recruitment procedures and Protection of Vulnerable Adults training protect the service users. EVIDENCE: Nine questionnaires were completed by residents and received by the Commission for Social Care Inspection prior to this inspection. All said that they knew who to talk to, should they be unhappy with their care. This was confirmed during discussions with some of the residents during this visit. Six of the seven questionnaires completed by families said that they were aware of the complaints procedure. One said that they had made minor complaints; “I have on occasions spoken to staff about minor issues, but each time the matter has been addressed straight away”. Staff are now receiving Protection of Vulnerable Adults training. This was confirmed in the staff training files and during discussions with staff. Staff files were checked at this inspection and recruitment procedures have improved therefore further protecting the residents. Criminal Records Bureau disclosures and Protection of Vulnerable Adults checks are obtained for all staff prior to employment. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 14 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, 20, 25 Work has been completed to ensuring that all of the Fire Safety Officers requirements are now met and that the safety of the residents is further strengthened. EVIDENCE: Since the last inspection the Fire Safety Officer has inspected the Home and a number of requirements were made. The proprietor was able to demonstrate that all issues have been addressed. One of the most important areas addressed is maintaining the safety and security for those residents with dementia care needs, whilst adhering to fire safety legislation. This has resulted in all doors being linked into the new ‘call-bell’ system and the front door being linked to a break glass system that is released by smashing the glass in the event of a fire. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 15 The garden area of the Home is attractive and nicely maintained. Some of the residents said that they had enjoyed going into the garden in the warmer weather. A tour of the bedrooms was not made during this visit, however the communal and ‘day’ areas were all seen. These are comfortable and pleasantly decorated. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 16 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, 28, 29, 30 The training opportunities have improved in the Home and the recruitment practices strengthened to ensure that suitable, trained and competent staff care for the residents. EVIDENCE: The rotas indicate that seven care staff work throughout the day and five in the evenings. Three staff work throughout the night. This was confirmed by the staff on duty as normal practice. Separate auxiliary staff are employed for the domestic, maintenance and catering tasks. Approx one third of the staff team have obtained NVQ 2 and seven staff are to be registered. The staff spoken to during this inspection were enthusiastic about training opportunities and are to be congratulated for their commitment. The training records have been re-organised and improved and therefore the monitoring of mandatory training is more easily achieved. There are a few gaps in the required mandatory training for staff but these are being addressed, for example food and hygiene courses have been booked. The senior staff responsible for medication administration are undertaking the module based ‘Safe Handling of Medicines’ training and staff confirm that they are being offered Protection of Vulnerable Adults training. Staff sign an attendance sheet at each training session. The proprietor is trying to access more in-depth training for caring for service users with dementia care needs. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 17 New staff complete an ‘in-house’ induction with the manager. This is followed by a mentor system, so that they can ‘shadow’ experienced members of staff. During their first six months of employment, new staff complete a comprehensive training booklet, which is signed off by the manager. The manager and senior staff are trained as manual handling trainers. Domestic and kitchen staff are offered the opportunity to undertake NVQ awards and they are also to be involved in infection control training. Three staff files were checked at this inspection. The files now contain all of the required elements listed in Schedule 2 of The Care Homes Regulations. The manager team expressed their concern that the staff team may not fully understand the reason for Commission for Social Care Inspection legislation and inspections and the responsibilities of the Regulating Authority, the care home and its staff. The inspector offered to attend a staff team meeting to answer their questions. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 18 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): 32, 33, 36, 37, 38 The management team have worked hard to address the requirements made at the inspection in November 2004 and many improvements have been seen during the two inspections in 2005. EVIDENCE: The residents and staff spoken to during this visit verified the approachability of the registered manager, Mavis Toft. The manager is now recording official staff supervision sessions, although she spoke of numerous unofficial discussions with staff, which are not documented. Staff confirm that they are having 1:1 supervision, attend staff meetings and that there is a handover session at the beginning of every shift. The proprietor has recently sent out thirty-nine quality questionnaires to relatives and families. At the time of this visit, twenty-five completed questionnaires had been returned. He is to collate the information and was Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 19 reminded that this information should be available to the residents and/or their families and the Commission for Social Care Inspection. Record keeping has continued to improve in the Home. The service users’ care records were seen to be better maintained and organised during the last visit in April 2005, however the staff files were not accessible at that inspection. These were available during this visit and training, supervision and recruitment records are now up to date and contain evidence of Commission for Social Care Inspection requirements. The proprietor provided the Commission for Social Care Inspection with a list of the Home’s Health and Safety, maintenance and associated records prior to the inspection. A random selection of these was confirmed during this inspection. Fire safety requirements have been addressed. Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 20 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X X 3 3 3 Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (2) 5(2) Requirement 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. A collation of the quality assurance results must be available to the residents and the Commission for Social Care Inspection. Timescale for action 01/12/05 2 OP33 24 (2) 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Orsett House Retirement Home DS0000004988.V253568.R01.S.doc Version 5.0 Page 22 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.V253568.R01.S.doc Version 5.0 Page 23 - 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. 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