Inspection on 16/01/08 for Orton Mere

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Orton Mere 13/01/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Orton Mere 547 Oundle Road Orton Longueville Peterborough PE2 7DH Lead Inspector Don Traylen Key Unannounced Inspection 16th January 2008 12:00 Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 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 Orton Mere DS0000070723.V358156.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 Adults 18-65. 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. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orton Mere Address 547 Oundle Road Orton Longueville Peterborough PE2 7DH 01638 606300 01638 606301 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) Ermine Care Ltd Mrs Charlene Gwidza Care Home 13 Category(ies) of Learning disability (13), Mental disorder, registration, with number excluding learning disability or dementia (13) of places Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection This is the first inspection Brief Description of the Service: Orton Mere was first registered as a care home on 27th September 2007. The home is registered to provide nursing care to people with Learning Disabilities and Mental Disorders. The building has been purposely converted in to a new care home during 2007. The home has 13 rooms that each have an en-suite shower room or bathroom and toilet. The home was originally built on two levels and has had an extension added that that has been built downwards and into the sloping land to the rear of the building and has resulted in three floor levels. The upper area has 3 bedrooms and the ground floor level has 10 bedrooms. There are a variety of sizes of communal rooms that offer the opportunity for some privacy. The manager’s office and staff cloakroom are located in the attic of the home and there are two further rooms, one on each floor, that are specifically for office use. There is a large garden to the rear and side of the home and a driveway and parking space for approximately ten vehicles at the front of the home. The building is surrounded at the front and side by hedges and trees. Fees range from £1950 per week. The home will make copies of the report available and these are also available on the CSCI website. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home completed an Annual Quality Assurance Assessments (AQAA) that was submitted to the CSCI prior to the inspection. One inspector conducted the inspection between 12 noon and 8:45 pm on 16h January 2008. One relative’s survey form and two care staff survey forms were completed. The manager was present during the inspection and intermittently provided me with documentation and verbal information about the service. Medication procedures were assessed, as were the admission process and arrangements and the care plans for the three people living at the home. Each person living at the home was met and spoken to. A consultant psychiatrist who is employed by the company spoke to the inspector about his role in prescribing medication. Two care staff were asked for their experiences of working at Orton Mere. Feedback of the findings was given to the manager during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: The registered providers have purposely converted the building into a care home. The newly registered service meets the National Minimum Standards for room sizes and communal facilities. The environment was particularly spacious for the three people living at the home at the time of inspection. The home was very clean and all equipment, furnishings and fittings, floor coverings were new and in very good condition. The kitchen is newly fitted and has satisfactory equipment and food and hygiene safety standards are applied. The large garden area is a secluded and usable facility and was adequately maintained, although plainly landscaped. Attention to determining a person’s needs prior to agreeing to accept them into the home is a careful and extensive process involving a multidisciplinary group of professionals from health and social care. The manager and staff are particularly aware of the necessity to balance the needs of people already living at the home with the needs of people being referred to live with them. The organisation employs a consultant psychiatrist and clinical psychologist who have considerable input and very regular contact with the home. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 6 The manager leads by example and has established an open and positive communications culture and this extends to people living at the home as well as staff. Some aspects of the training provided were good, such as the two-week extensive induction programme provided for staff prior to the home opening. An observational based on the good practice seen in the reporting of concerns of abuse and considering the staff ratio for the few people living at the home, is that the home may face greater challenges in the future, if more people live there. Only three people were living at the home at the time of this inspection and there were adequate staffing levels. Should more people move into the home then it is anticipated that the dynamics of personal space and staffing ratios may present new challenges. What has improved since the last inspection? What they could do better: The home’s Statement of Purpose must be kept under review so that it accurately reflects the service. The home should try to involve the family and relatives at an early stage of the admission process if it is appropriate, so that they can better determine a person’s needs for social inclusion and facilitate or continue any family contacts and relationships. The medication administration record (MAR) charts must be improved so that it is possible to calculate if the medication held by the home matches the records shown on the MAR charts. The records must show a precise date and time of when the medication has been started, as well as the amounts in numbers of this medication. A plan for the reasons and indications for the administration of any person’s prescribed PRN medication must be recorded as clear guidance for staff to follow. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 7 The induction programme and training for new care staff should be organised and provided immediately new staff commence employment at the home and staff should not have to wait for a date when the organisation has set a date to provide an induction programme to a group of new workers. Records of the induction must be maintained and the level of competency achieved during the induction programme should be recorded. A training plan to prepare for the ongoing training provision for all staff must be established and should be written. The supervision arrangement for all staff must be attended to. 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. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4, Quality in this outcome area is good. People moving into the home are assured they receive a good evaluation and assessment of their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose did not accurately describe some aspects of the service. The numbers of care staff that were quoted were not the same as those in reality on the day of inspection, but were the projected or intended numbers of staff. However, given the very complex and intensive needs of people living at the home, the manager agreed that the staffing levels would be continuously reviewed. The Statement must be reviewed to reflect the home’s actual status. The assessment documents and the assessment process for the three people living at the home were read and discussed with the manager and with some of the care staff. The home works very closely with Health Service and social care professional in a multidisciplinary process to carefully assess and determine the needs of people who have been referred to the home. The multidisciplinary team consists of professionals from Mental Health Trusts and Learning Disability services and often involve a psychiatrist and clinical psychologists employed by the organisation and specialist therapists. The process is extensive and necessarily lengthy and often staff are involved in the pre-planning and are sensitively introduced to the person in a considered Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 10 manner. Care staff were fully informed and prepared for the complex needs and the challenging behavioural needs of people referred to the home. Where it is appropriate, people will visit the home prior to moving there, so they can become familiar with and adjust to a new environment and to new people. This careful assessment process is essential and deliberate so that the home is prepared and are confident to support people and to meet their challenging needs. The manager stated that the home has planned to gradually increase the numbers of people living there, so they can manage the demands, risks and challenges when trying to meet complex needs. Only three people were living at the home on the day of inspection. One relative commented in her survey that she was unaware of her brother-in -law being placed at the home until after he had moved there. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is good. People are assured their care plans are available to them and they participate in the decision-making and determine their risk taking. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three people living at the home were read. The plans were well presented documents with indexes that made easier reading and links between the different sections. For instance, there were clear links shown when assessed risks had been converted into care plans. Not all risks assessed had been written into plans but where risks had been assessed as significant, a plan of care was written. The plans were extensive documents. During the day of inspection two people attended their care reviews. These reviews involved a multidisciplinary team from Mental Health services and Learning Disability Partnership and the key worker, or the named Nurse, from the home. The home has regular internal handover meetings and progress meetings and their own multidisciplinary group meet every two weeks to discuss in depth the care Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 12 arrangements for each person living at the home and this includes the staffing levels they consider necessary. One person expressed his own plan of progression and had a clear expectation of where he wanted to live in the near future. This was being planned with him. The way he described his intentions and discussed them showed that his right to make decisions was respected and he was being enabled to do so. Staff had provided him with information about the place where he wanted to eventually live and about places that he wanted to see and to travel to. There was a discussion about his aspirations that showed he was an equal participant and was making decisions about his life and immediate care. The home is very aware of the risks presented by people living at the home. The care plans are realistic in how people will be supported to take risks and how these risks may affect health and lifestyle. One person’s behavioural risks had been recorded in his care plan for their frequency and had been recorded and referred to the PCT’s Adult Protection Unit and to CSCI in Regulation 37 reports. People were protected from these risks and strategies had been put into place to prevent and to deter challenging behaviour when warning signs had been identified. Another person’s care plan who had moved into the home only two days previously showed that the ‘risk summary’ and a ‘chronology of events’ forms used by the home had not been updated, although recent events had been recorded elsewhere in the clinical records kept by the manager. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,15,16,17, Quality in this outcome area is adequate. People are not fully assured of a planned approach to enjoying and achieving greater social stimulation and development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans showed less about social development than the medical model of care. Whilst there was verbal information provided by the manager about further education and leisure pursuits for two people there was no recorded plan or social calendar for them. Social development was seen in enabling people to plan their meals and to use the laundry and to be prepared to asking for their medication. The manager is keen that people develop socially and is mindful of the progressive approach and move-on facility that can be provided by this home for people who are ready for a more independent life. The manager explained the focus and intention is for people to develop socially through their Activities of Daily Living (ADL) within the domestic setting of the Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 14 home and for people to become more self-sufficient. However, any achievements of domestic and social tasks had not been recorded. Engaging in the community and a planned approach to any educational and leisure activities was not occurring for each person, one of who had moved into the home less than two days before. Family links were in place for one person living at the home. Care workers and the manager were seen to be respectful and genuine in their conversation and equal treatment of people living at the home. During the inspection a lunchtime snack of sandwiches meal was eaten on the day of the inspection rather than the planned cooked meal that is usually provided during the day. Lunch had been re-arranged because two people had their care reviews on the day. The recently appointed cook recorded a choice of meals and a four-weekly rotational menu. The recorded menu appeared to be nutritious and varied. One person stated he liked the food but that he did get enough to eat. He was seen to enjoy his food and talked about food with great interest. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is adequate. People living at the home would benefit from a more accurate recording of medication held by the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One person informed the inspector he was receiving the support he wanted and staff were helping him to plan his future. Care plans indicated the amount and type of emotional and functional support planned. Care review processes are held fortnightly to monitor each person’s emotional and mental stability and functioning as a clinical process. A multidisciplinary team is committed to this reviewing and management process. Nobody self-medicates. People had been assessed for risks and choices in this matter. However, people were encouraged and supported to remember their medication and were expected to take some responsibility in this. One aspect of administering medication was by offering medication to people over a splitlevel door to the medication room. This practice did have a positive intention to place some responsibility on the person to make a physical and mental effort and exercise choice about taking their medication. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 16 The Medication Administration Records (MAR) charts are hand written by the consultant psychiatrist whenever he prescribes any medication and are also rewritten by him each month. There were no copies of the actual prescriptions and no way of telling if the handwritten MAR charts were of the medication prescribed. Medication is provided in individual packages with the prescription label. The charts did not include the numbers for the amounts of tablets being used. There was a separate record of the medication received by the home, but when it was checked and counted with the manager, it was not possible to be sure that the remaining medication was accurate because there were no figures to indicate the date and time when the medication had been started. A requirement has been made in this matter so that the records show a precise record of when the medication has been started, as well as the amounts in numbers of this medication. After discussing these matters with the manager and the consultant psychiatrist the manager stated that the pharmacist was prepared to provide a pre-printed MAR chart and this would include the amounts of medication provided. The manager is considering whether to use these charts in the future. The MAR charts did not have any space to write text to explain any refusals or other or any different reasons or discrepancies noticed. In the case of one person prescribed ‘PRN’, or ‘as required’ medication, there was no written protocol for administering his medicine that was available in his care plan or in the MAR chart. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is good. People who live at the home are protected from abuse by the home’s practice and their policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy and a policy to protect vulnerable adults. The manager has kept a useful and informative reference file about adult protection procedures and guidelines that included Peterborough Primary Care Trust’s protocol and information about the POVA first listing as well as the home’s policy for the Prevention of Abuse. Contacts to inform the Police and Lead Practitioners were written in the file. Appropriate referrals to the PCT about allegations of abuse had been made by the home that had been investigated by the Lead Practitioner from the PCT. These referrals had also been referred to the Commission via The Care Homes Regulations 2001, Regulation 37 reports. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30, Quality in this outcome area is good. People benefit from a comfortable, clean and recently modernised and refurbished home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had undergone a full refurbishment programme before it was opened as a registered care home in late 2007. The property has been adapted to modern standards. All rooms have en-suite facilities and are spacious and with adequate natural light. The home was clean without any offensive odours and there are adequate communal areas and as well as smaller rooms where some privacy can be expected. There were only three people living at the home at the time of inspection who benefited from the quiet and very spacious environment. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36, Quality in this outcome area is adequate. People living at the home are not assured that the home has planned to consistently train care staff or consistently supervised their work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One care support worker started work for the organisation on 23/7/08 and did not work until the home opened on 03/10/07 but did not have a CRB disclosure until 16/10/07. There was no record of a POVA first check for this person and no record of how she was supervised at the commencement of her employment. This person had received a thorough two weeks induction programme consisting of the basic Skill for Care Standards Induction standards for Learning Disabilities. Six care staff, including qualified nurse and unqualified support workers, had been provided with the same two-week induction training session in July 2007 in preparation for opening of the home in October 2007. This arrangement was a well-managed way of providing an induction programme for new staff before the home opened and included training in Autism, Asperger’s Syndrome and Challenging Behaviour. Two care staff who commenced work after the home had opened on 16/10/2007 Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 20 received a very different and brief induction, provided by the manager. Their induction was not of the same duration or equal to the induction provided for the six previously mentioned care staff. The manager had not been trained to provide Adult Protection training although she had included this topic in the induction she provided for these two care workers. A record for their induction was not available and there was no recorded measurement of their competencies achieved during their induction. Two care support worker staff said they wanted additional training in the Mental Capacity Act and wanted to undertake higher NVQ awards in care and would like to be able to have Internet access in the home so they could enhance their knowledge. One care worker said he had not received supervision since commencing employment in October 2007. The staff training policy that was read stated that the home would train all care support workers to NVQ level 2 awards in care and this training would include the Learning Disability Awards Framework. The home employs 9 staff, including the manager and 4 registered nurses, an administrator, a maintenance worker, a cook and cleaners. At least one registered nurse with Mental Heath or Learning Disability qualifications is always working at the home. During the inspection the home was staffed by one nurse and two support workers, plus the manager. Following an incident during the inspection, the manager decided to request an additional person to work the night time shift, which meant there were four care staff and a nurse working during the night time. The organisation provides a specialist psychiatrist and a psychologist to give expert assessment and management of rehabilitation plans. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42, Quality in this outcome area is good. People are assured the home is run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well run. The registered manager is a registered nurse and leads by example of good communications and a friendly but clear approach to staff that was observed during the inspection. Staff reported they could speak openly and honestly to the manager and that regular team meetings were held. However, it has already been reported that supervisory arrangements had not been consistently applied to all staff. The manager explained how she is preparing to employ more care staff when new admissions to the home are planned. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 22 Weekly fire alarm testing had been carried out and recorded. The fire system had been tested and an annual fire test certificate had been obtained. A full time worker manages the general maintenance of the building and the request for any maintenance is conveyed through a communications logbook kept by the home. A well -documented and very informative services and maintenance record book is kept by the full time maintenance worker. The maintenance worker ensures that hot water temperatures are safe. A range of appropriate and relevant policies is kept in the home. Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 3 X 3 X Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 24 N/A Are there any outstanding requirements from the last inspection? Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 6(a) Requirement Timescale for action 01/03/08 2 YA20 17(1)(a) 3 YA20 13(2) 4 YA34 19(10) 4 YA35 5 YA35 17(2) & Schedule 4 18(1)(c) 5 YA36 18(2) 7 YA36 18(2) Orton Mere The Statement of Purpose must be kept under review so that it provides the reader with current information about the home. Medication Administration 01/02/08 Records must be accurately recorded so that they give a precise indication of the amount of medication held by the home. There must be a recorded 01/03/08 protocol for each person for the reasons for administering any PRN medication prescribed for them so that nobody is at risk of overdoing or under dosing. Staff records must show that a 01/03/08 person has received a POVA first check before commencing work so that people living at the home are not put at risk. A training plan for all staff must 01/03/08 be made so that people are assured adequately trained staff will support them. Written evidence of a structured 01/03/08 and formalised Induction based on the Skills for Care Standards must be provided for all staff. Suitable supervisory 01/03/08 arrangements must be made and recorded for care staff who commence employment prior to receiving a satisfactory CRB disclosure. All staff must receive regular 01/05/08 supervision so that people living at the home are assured staff are monitored and supervised. DS0000070723.V358156.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The forms used by the home in the care plans to record the ongoing circumstances and changing or challenging behaviours so that there is an accurate indication of a person’s changing needs. Personal development of people living at the home should be planned and should be monitored and able to be assessed and recorded for potential progress or change. The manager should undertake the appropriate training provided by the PCT so that she is better able to provide induction training in adult protection to new care staff during their induction period. Induction competencies should be recorded so that the home are able to assure people that staff have reached a basic level of competency. Additional training in Adult Protection should be provided by the Local Authority for staff who have not been trained by Local Authority trainers. 2 3 YA11 YA32 4 5 YA35 YA35 Orton Mere DS0000070723.V358156.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Orton Mere DS0000070723.V358156.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. Re-publishing this information is in breach of the terms of use of that website. 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