Inspection on 23/01/07 for Scotch Orchard

This inspection was carried out on 23rd January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scotch Orchard 10/12/05

Scotch Orchard 01/09/05

Scotch Orchard 11/10/04

Scotch Orchard 02/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Scotch Orchard 55 Scotch Orchard Lichfield Staffordshire WS13 6DE Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 23 January 2007 09:15 Scotch Orchard DS0000034865.V311571.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 Scotch Orchard DS0000034865.V311571.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. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scotch Orchard Address 55 Scotch Orchard Lichfield Staffordshire WS13 6DE 01543 264755 F/P 01543 268970 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) Staffordshire County Council, Social Care and Health Directorate Miss Kelsay Suzanne Johns Care Home 14 Category(ies) of Dementia (4), Dementia - over 65 years of age registration, with number (2), Learning disability (14), Learning disability of places over 65 years of age (2), Mental disorder, excluding learning disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (2), Physical disability (5) Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 December 2005 Brief Description of the Service: Fifty-Five Scotch Orchard is a Local Authority Home that can accommodate thirteen younger adults with learning disabilities; two of the beds are for respite care. The home needs to apply for a minor variation to reflect accommodation for 13 adults. The home is located within private grounds in a residential area of Lichfield. Local shops are within walking distance, and the town centre is accessible by public transport. Service users have the use of a seven seated car. The accommodation comprises of ten single bedrooms on the first floor and three bedrooms on the ground floor. There are four bathrooms, two of which have an assisted bath, and adequate toilet facilities. The ground floor consists of three lounge/dining rooms, a patio lounge, and a hallway with a seating area. There are adequate service facilities including kitchen and laundry areas. There is a separate respite area on the ground floor incorporating a kitchen/diner, a lounge and two of the ground floor bedrooms. There is a patio area to the rear leading to a large grassed garden. The home provides accommodation to individuals with learning disabilities and complex needs. Individuals use a local Day Care facility during the week and staff support individuals to access community facilities and services in the evening and at weekends. There is a high staffing ratio in the home and the community as individuals may require a one-to-one or two-to one support ratio. A registered manager, a deputy, and a team of care managers and support workers provide care. The Deputy Manager is currently overseeing the management of the home four days a week, as the registered manager is providing support in another Local Authority home. NHS professionals and facilities are accessed as and when required. A local GP practice and a pharmacist service the home. The registered Manager on 23 January 2007 reported that the fee level for the home is £643.65 per week. For individuals receiving respite care, there is a charge of £19.21 per night. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 8 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection visit, survey information has been obtained from service users and their relatives. Two comment cards were received back from a service user and a relative. The manager had completed a Pre-inspection questionnaire. A tour of the home was undertaken. The inspection included an examination of records, indirect observation, discussions with three service users, the manager, and the staff on duty. Case tracking of three care plans was undertaken. Three staff records were examined and observation of daily activities took place. Medication storage systems and records were inspected. Two requirements and one recommendation were made as a result of this visit. What the service does well: The home has a staff group that is balanced and diverse to enable individuals a choice of male or female staff, and the staff team are of varying ages. The staff have open and positive relationships with service users and are aware of individuals needs, and how to manage complex behaviour. Staff communicate at a pace to suit individuals and using appropriate forms of communication. Service users are relaxed in the company of staff. In the absence of the manager, the management team have continued to work closely to ensure a good service is provided to individuals within the home. Senior staff have been able to develop new skills and take an increased role in the daily managements tasks, resulting in a confident and competent group of staff. Service users have a Person Centred Plan that has been designed to support individuals to play an active role in the care planning and review process. The plans are written in plain English and supported by pictures. Due to the complex needs of individuals, the plans are also reviewed with a service user representative where possible. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 6 Plans of care include assessments of risk for activities in the home and the community and agreements to any emergency physical restraint that may be required. A record of any restraint used is recorded and reviewed. Staff within the home complete training for managing complex behaviour and work together as a team to minimise any distress to individuals and other members of the staff team. Individual’s personal support and healthcare needs are well documented and staff are knowledgeable regarding individuals needs. The home has developed good working relationships with health care professionals and external agencies. Individuals benefit from having a large resource of professionals and support agencies to call upon to assist in meeting their needs and supporting staff with training. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed a comprehensive Statement of Purpose and Service User Guide, which is very specific to the service user group, and is available in pictorial format. EVIDENCE: The home has a Statement of Purpose and Service user, which reflects the service provided. These documents were reviewed in December 2006. The Statement of Purpose records the home is able to accommodate thirteen persons. The home is registered to provide accommodation to fourteen people. Discussion with the manager revealed that one room is used as the staff room. The registered person must submit an application for a minor variation for thirteen people to reflect the accommodation in the home and the Statement of Purpose. Inspection of three records revealed that two new people admitted since the last inspection had been part of a comprehensive assessment through the care Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 9 management process. A record of individuals needs and the support required, and relevant history was provided and remains available in the home. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plan is presented in a format that ensures the individual can access and understand the information that it contains and is written in plain English with pictures. EVIDENCE: Inspection of three plans of care revealed that the home has continued to implement individuals Person Centred Plan. The plans have been designed to enable service users to take an active role in the care planning process and the plans have specific needs and goals, and are supported by pictures. An example of the plans is, ‘Would you like to receive your own mail? Do you want to share information with others? Specific needs and goals are recorded on an action plan and are linked where appropriate to a detailed assessment of risk. Examples of the plan for Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 11 recording complex needs includes, ‘There are occasions when I become aggressive’ this leads to recording what should then be done. Individuals living in the home have very complex needs and assessments of risk include agreed strategies for management of behaviour and where necessary agreed methods of restraint. The home records any restraint and the manager completes an audit. It is recognised that due to the dependency levels of the service users, the individuals may not be able to take an active role in all parts of the care planning and review process. The home invites cares to participate in this process and a record is maintained of all persons including other professionals that are involved. Discussion with staff revealed that the care plan is a working document and staff are given to time to be familiar with the plan and informed of any changes. Staff demonstrated a good knowledge of recorded needs. The home operates a Key worker system and support workers have a link worker role. This system enables staff to establish a relationship with individuals and to be a primary source of information. The plan of care includes details of decision making, and from observation of practices staff were encouraging individuals to make decisions and informed choices in all daily events. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; individuals have involved in the planning of their lifestyle and quality of life. EVIDENCE: The Plans of Care records the support individuals require in the community and includes an assessment of risk. Due to the complex needs of individuals, a number of service users require a one to one or two to one support from staff. Staff also need to be trained to manage complex behaviour. All service users living within the home attend the local Day Care Provision. Staff reported that leisure activities are focused on the weekend or holiday periods. The home has sole use of a seven seated vehicle. Recently staff Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 13 reported that service users have been bowling and to the cinema, to a local Gateway Club, Branston Water Park and to Lichfield. Two service users have attended a football match. There is a range of activities in the home for service users to access including sensory equipment. Staff reported that in the evenings, a number of service users prefer to relax and watch a DVD or listen to music. One individual was observed playing cards, supported by a member of staff. The also is able to accommodate up to two people on a respite basis. Staff reported that individuals are able to stay in the separate respite annexe or socialise with other service users. Many individuals are known to the service users from the Day Service. Individuals are able to receive visitors on a flexible basis and some service users stay at family members home. Due to the complex needs of the service users, staff at the home encourage carers to be involved in the person centred planning process. Breakfast is served from a hostess trolley in the two lounge diners. Service users are supported to choose and prepare their breakfast. The other meals are prepared in the main kitchen by the cook or staff. Staff reported that service users were able to have a choice of meals and an audit of food waste is conducted to try and monitor preferences. One of the lounge areas has a small kitchen where individuals, following an assessment of risk are able to make snacks and drinks. Two service users were able take an active role in maintaining their bedroom and staff reported that where possible individuals are included in the daily running of the home. Individuals are responsible for purchasing their clothes and personal items and receive support from staff when going shopping. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff group is balanced to enable choice of male, female and age related preferences when delivering personal care. Staff respond appropriately and sensitively in all situations involving personal care and when managing complex behaviour. EVIDENCE: The plans of care record individual’s health care needs, including visits to health care professionals and details of any outcomes. The home has close links with the community nursing team, who are involved in delivering training to staff, reviews of plans of care an monitoring any identified health care need. Individuals also have access to a Consultant Psychiatrist. All individuals are registered with a local General Practitioner. On the day of the inspection, one individual was supported on a two to one basis to visit their doctor at the community practice. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 15 One plan of care inspected recorded details of dietary needs and following a speech and language assessment details of how staff were to support the service user, a suitable diet, and the consistency of required foods. Where appropriate continence assessments have been carried out with health care professionals, with staff recording and monitoring the necessary details and information. The staff group is balanced and diverse to enable individuals a choice of male or female staff and the staff team are of varying ages. From observation, it was noted that individuals were able to choose whom they wanted support from and staff were flexible in their approach. Appropriate forms of communication were used, including forms of non-verbal communication and Makaton. Medication is stored in a locked medicines trolley in the office. The Monitored Dosage system (MDS) is used. Individual’s cassettes include a photograph of the service user. Inspection of records, storage and procedures revealed the home has robust systems in place to safeguard individuals. Where individuals require medication at the Day Care provision the Pharmacy dispenses the medication in a separate pack. Staff at the home and Day service staff complete a form detailing the medication and quality and both individuals sign. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is up to date, clearly written, and is easy to understand. It can be made available on request in a number of formats. The information informs individuals and carers of what can be expected to happen if a complaint is made. EVIDENCE: The home has a suitable complaints procedure in a written and pictorial format. Scotch Orchard is a Local Authority Home and all documentation can be requested in a number of different formats, including other languages and large print. There have been no recorded complaints since the last inspection. Individual’s personal monies are held securely in the home. Staff record all transactions and two staff sign for monies out or when returned. Staff have received training for recognising signs of abuse and the Vulnerable Adults Procedure. Discussion with staff revealed they would be confident in managing a disclosure. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 17 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, 25, 27, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the individuals who live there. All service users have a large single bedroom that is decorated to reflect their interests. EVIDENCE: Fifty-Five Scotch Orchard is a Local Authority Home that can accommodate thirteen younger adults with learning disabilities; two of the beds are for respite care. The home needs to apply for a minor variation to reflect accommodation for 13 adults. The home is located within private grounds in a residential area of Lichfield. Local shops are within walking distance, and the town centre is accessible by public transport. Service users have the use of a minibus. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 18 The accommodation comprises of ten single bedrooms on the first floor and three bedrooms on the ground floor. There are four bathrooms, two of which have an assisted bath, and adequate toilet facilities. The ground floor consists of three lounge/dining rooms, a patio lounge, and a hallway with a seating area. There are adequate service facilities including kitchen and laundry areas. There is a separate respite area on the ground floor incorporating a kitchen/diner, a lounge and two of the ground floor bedrooms. There is a patio area to the rear leading to a large grassed garden. The home has a shaft lift to gain access to the first floor. All bedrooms were of a good size, decorated to a high standard and had been personalised by service users to reflect individual preferences. There was a range of sensory equipment, electrical appliances and soft furnishings. The showers are not being used, as there is evidence of Legionella. The home has carried out assessments of risk and flush the system as instructed. A copy of the required monitoring and flushings are kept in the home. Regular tests have been carried out and the measures put in place have reduced any risk to individuals or staff. Scotch Orchard DS0000034865.V311571.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, 33, 34, 35, 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a diverse staff team that has a balance of all the skills, knowledge and experience to meet the needs of service users. There is evidence that they demonstrate a thorough understanding of the particular needs of the service users. EVIDENCE: On the day of the inspection there was one care manager working from 7.15 – 3.30 and five support workers from 7.15 – 9.45 or 10.00. The home provides minimal staffing during the day as all service users attend a local Day Service provision. Staff are available for any emergency and rosters are changed during holiday periods. In the afternoon, there were two care managers and three support workers. Two members of staff were also completing their induction. In addition there were two domestic staff working from 7.30 – 12.00pm, a laundry assistant working 8.30 – 12.00, a handyman working from 8.00 – 12.00pm and the cook worked from 2.00 – 6.30pm. Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 20 The home has a robust recruitment procedure that ensures that staff are suitable to work with vulnerable people. A sample of three staff files were examined and demonstrated that thorough pre employment checks are carried out. Criminal Records checks had been undertaken in all instances, and there was proof of identity, two references and a completed application form on file. Staff reported they receive a comprehensive Induction in line with the Care Sector Skills Common Induction Standards. Staff also receive an induction for the Policies and Procedures of the home. Staff received formal supervision bi-monthly with the manager. The manager and staff reported that the supervision process identifies areas of needs and training and gives an opportunity to review care practices. Staff have opportunities to identify training needs and have access to a wide range of training courses through the Local Authority and external agencies. Inspection of records and discussion with staff revealed staff have received training for infection control, safe eating and drinking, Fire training, the Vulnerable adults procedure, moving and handling, health and safety and managing complex behaviour. From discussion with evident that staff are quality service. Staff communication and an required. the staff team and observation of practices, it was extremely enthusiastic and committed to providing a commented that they work well as a team with good awareness of staff strengths and areas where support is Staff carry a nurse call pager on each shift, which enables them to summon support and help, or respond to a call. All staff spoken with stated confidently that the team of staff work well together in managing complex behaviour. Where possible incidents are diffused. Where physical restraint is used the staff team work together with a designated person in charge of the incident to co-ordinate staff. A detailed record is completed and reviewed by the manager. Staff have an opportunity to discuss the incident and review what happened, how it was managed and whether this could have been done differently. This is an area of good practice. Scotch Orchard DS0000034865.V311571.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, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualification and experience but is primarily covering another local authority home. The team of senior staff are managing the home on a daily basis. The outcomes for service users remain good but the home needs to ensure the registered person needs to ensure suitable management arrangements are in place within the home to meet registration requirements. EVIDENCE: The registered manager is currently working four days a week at another Local Authority Establishment for a number of months. This was discussed with the manager and Service Development Manager. It is required that the registered Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 22 Person informs the Commission of the future management arrangements with detailed timescales; the management arrangements will be reviewed by the Commission, regarding future outcomes for the home. During this period, the Deputy Manager has been overseeing the management of the home, supported by the team of Care Managers. It was evident from the findings of the inspection that the Deputy Manger has continued to ensure high standards within the home and the registered manager has remained available for any queries and problems, and worked in the home one day a week. The Care Managers reported that they have additional duties to perform, though this has been positive and staff reported that this has enabled development of further skills. A representative from Staffordshire Local Authority completes an unannounced monthly monitoring visit; a record of the visit is maintained in the home. There was evidence that regular tests and drills take place and a Fire Risk Assessment was in place. Entries for fire drills contained the names of persons involved; this was discussed with the deputy manager. It is recommended that a Matrix be developed to clearly identify which staff are involved to ensure all staff receive adequate fire training and are involved with evacuation. The home completes required checks and maintenance including, Fire extinguishers July 2006 Gas Safety test January 2007 Portable Appliance testing January 2007 Bath Hoists June 2006 Shaft Lift November 2006 The home now completes a quality audit with service users. This system uses the outcome groups of the National Minimum Standards, and uses direct questions and pictures to support individuals to complete the audit. The forms were suitable for some people who have learning disabilities and the documents were seen as good practice. Scotch Orchard DS0000034865.V311571.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 X 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 4 26 4 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 X 3 X 4 X X 3 X Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation Care Standards Act Part II 24 (1)(2) 10 (1) Requirement To submit an application for a minor variation for the home to accommodate 13 persons as recorded within the Statement of Purpose The registered person is to submit a report on the current interim management arrangements, including timescales for the CSCI to consider the need for an application to be made for a registered manager Timescale for action 28/02/07 2 YA37 07/03/07 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 Refer to Standard YA42 Good Practice Recommendations To develop a staff matrix for recording Fire evacuations Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford 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. Extracts may not be used or reproduced without the express permission of CSCI Scotch Orchard DS0000034865.V311571.R01.S.doc Version 5.2 Page 26 - 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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