Care Home: Brandley Ltd. (Orchid House)

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What the care home does well A care plan was developed for each person. Plans were easy to follow and included useful information about the person`s individual needs and history. People were supported to attend medical appointments and to take their medication regularly Staff supported people to pursue personal interests and hobbies in the home and community. During the summer months everyone was able to get away from their regular routine and relax on holiday. Staff worked hard to help people to stay in touch with old friends and family and encouraged people to contribute to the running of the home. The food provided in the home was varied and people were able to choose what they ate. The home had not received any complaints but staff knew what to do if concerns were raised about the service. The home was maintained to a satisfactory standard and all areas were clean, welcoming and comfortable. The home has a stable, well-trained team of staff. This helped the people that lived in the home to feel comfortable and safe. Access to training was good and staff felt supported and valued. The home was well managed and led. What has improved since the last inspection? The manager and staff had worked hard to address all of the previous requirements. The manager was aware that medicines that were no longer in use must be marked as discontinued and signed and dated. The medication procedure had been reviewed and updated but some additional information was required to ensure that staff had access to adequate information. Staff files were well organised. Criminal record bureau checks were recorded and were made available for inspection. Staff had identified that some written information was not presented in a format that suited the people that lived in the home. A development plan was prepared to address this issue. Cleaning solutions and other hazardous substances were stored securely. Refrigerator and freezer temperatures were monitored regularly and opened food was stored appropriately. Fire drills took place regularly and were recorded. What the care home could do better: Support plans provided guidance for staff about peoples preferred routines and care needs but information about progress with personal goals was not always recorded. The management of medication was mostly satisfactory but some information was not always recorded. The training that was provided for staff that were responsible for giving out medication did not meet the required standard. Some of the written information developed by the home was not easy for people with learning disabilities to follow or understand. The home had identified this issue and was starting to undertake some work to provide support plans, activity records, a complaints procedure and satisfaction surveys in a more suitable format. The ground floor shower room felt cold and one of the bathroom door locks were missing. The Registered Person must ensure that the people have adequate privacy and that a comfortable temperature can be achieved. Staff kept up to date money records but some of the entries in the records did not provide adequate information about how people`s money was used.The manager carried out thorough checks before allowing new staff to work in the home but did not always check that references were genuine. Health and safety issues were addressed promptly but there was no evidence that the emergency lighting system was serviced. There were systems in place to monitor the quality of care provided in the home but the frequency of audits and checks was unclear. CARE HOME ADULTS 18-65 Brandley Ltd. (Orchid House) Orchid House 49 Elsenham Road Manor Park London E12 6JZ Lead Inspector Maria Kinson Unannounced Inspection 19th October 2007 10:05 Brandley Ltd. (Orchid House) DS0000062815.V354084.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 Brandley Ltd. (Orchid House) DS0000062815.V354084.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. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brandley Ltd. (Orchid House) Address Orchid House 49 Elsenham Road Manor Park London E12 6JZ 0208 478 1517 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) Beverley.beaupierre@btinternet.com Brandley Ltd Ms Beverley Beaupierre Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To allow the home to provide continuous care for a named service user, who is now over the age of 65 years. 16th June 2006 Date of last inspection Brief Description of the Service: Orchid house is run by Brandley Residential Homes. The home is a threebedroom property in a residential road in the borough of Newham. The home is registered for three adults between the ages of 18 and 65. However a variation has been obtained for a service user who is now over 65 years of age. The service users all have a learning disability. The home offers care and support in a homely environment. There are pleasant shared spaces including a family kitchen, lounge and a small garden. Showering, bathing and toilet facilities are good. The office/sleep in room is located upstairs and includes an en-suite shower room. The current fees range from £870- £975 per week. This does not include additional charges such as holidays, clothing, toiletries, hairdressing and recreational activities. This information was supplied to the commission on 07/11/07. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 19/10/07 and was unannounced. The inspector spoke with all of the people that lived in the home, one member of staff and the manager. Care, medication, health and safety, money and staff records were examined. Five members of staff, two relatives and six health care professionals were asked to provide written feedback about the home. Two responses were received from health care professionals and staff. Some of the comments and information obtained about the service are included in this report. At the time of this inspection there were three people living in the home. What the service does well: A care plan was developed for each person. Plans were easy to follow and included useful information about the person’s individual needs and history. People were supported to attend medical appointments and to take their medication regularly Staff supported people to pursue personal interests and hobbies in the home and community. During the summer months everyone was able to get away from their regular routine and relax on holiday. Staff worked hard to help people to stay in touch with old friends and family and encouraged people to contribute to the running of the home. The food provided in the home was varied and people were able to choose what they ate. The home had not received any complaints but staff knew what to do if concerns were raised about the service. The home was maintained to a satisfactory standard and all areas were clean, welcoming and comfortable. The home has a stable, well-trained team of staff. This helped the people that lived in the home to feel comfortable and safe. Access to training was good and staff felt supported and valued. The home was well managed and led. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Support plans provided guidance for staff about peoples preferred routines and care needs but information about progress with personal goals was not always recorded. The management of medication was mostly satisfactory but some information was not always recorded. The training that was provided for staff that were responsible for giving out medication did not meet the required standard. Some of the written information developed by the home was not easy for people with learning disabilities to follow or understand. The home had identified this issue and was starting to undertake some work to provide support plans, activity records, a complaints procedure and satisfaction surveys in a more suitable format. The ground floor shower room felt cold and one of the bathroom door locks were missing. The Registered Person must ensure that the people have adequate privacy and that a comfortable temperature can be achieved. Staff kept up to date money records but some of the entries in the records did not provide adequate information about how people’s money was used. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 7 The manager carried out thorough checks before allowing new staff to work in the home but did not always check that references were genuine. Health and safety issues were addressed promptly but there was no evidence that the emergency lighting system was serviced. There were systems in place to monitor the quality of care provided in the home but the frequency of audits and checks was unclear. 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. Brandley Ltd. (Orchid House) DS0000062815.V354084.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 Brandley Ltd. (Orchid House) DS0000062815.V354084.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager obtained and considered information about people’s needs and preferences before agreeing that the person could move into the home. EVIDENCE: It was not possible to assess the arrangements and procedures followed by staff when admitting new people into the home, as all of the people living in the home had done so for over two years. The manager said that prior to admitting new people into the home she would obtain a copy of the persons care needs assessment from the funding authority and carry out her own assessment. These records were seen in people’s files. Brandley Ltd. (Orchid House) DS0000062815.V354084.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, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support plans provided detailed information about people’s individual needs and strengths. The people living in the home were learning to make decisions for themselves with support and encouragement from staff. EVIDENCE: The care records for two people were examined. The files included detailed information about the person’s history and background, an individual support and activity plan and risk assessments. Information in support plans was easy to follow and was person centred. Plans were reviewed regularly and there was evidence that people using the service were involved in this process. Efforts were being made to present information in a user-friendly format using symbols and pictures. Personal goals were recorded but it was not always clear what progress the person had made. For instance one person wanted to be able to use the telephone and take some photographs. There were no references to their progress in the records. See recommendation 1. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 11 The people living in the home looked relaxed and said they liked living at Orchid House. They were not able to provide any detailed feedback about their experiences in the home. Care plans provided guidance for staff about promoting personal choice and acknowledged that some of the people living in the home were not used to making decisions for themselves. Staff supported the people living in the home to make choices and to become more independent. Records showed the people using the service were encouraged to participate in the running of the home. Some people had assisted staff to purchase food for the home, to prepare and serve meals and to collect their laundry. The monthly house meetings provided people with an opportunity to put forward ideas or suggestions and to raise concerns about the service. Topics for discussion were presented using pictures. The minutes from recent meetings included comments about college courses, Christmas celebrations and Halloween. Information about peoples preferred form of address was recorded and used by staff when talking with the people living in the home. Staff communicated effectively and showed concern and respect for the people they were supporting. Brandley Ltd. (Orchid House) DS0000062815.V354084.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to pursue personal hobbies and interests and to maintain contact with their family and friends. EVIDENCE: Records included a weekly activity plan. Staff recorded information in the person’s daily diary about activities or events that they had taken part in or attended. The records that were viewed for one person showed that they had undertaken a variety of different activities during the previous month such as music and drama classes at college, lunch at a local café, shopping trips, visited the local library, barbers and a park and went for a drive. At home the person liked to spend his free time watching television and listening to music. The fees charged by the home include one weeks holiday each year. During 2007 the people living in the home spent two separate weeks at a holiday Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 13 camp in Clacton. The manager said that everyone enjoyed the trip so much that a decision was made to fund an additional week. People could attend educational classes and opportunities to learn new skills at local colleges were explored during life plan and key worker meetings. The people living in the home had little contact with relatives but efforts were made to help people to keep in touch with their relatives and friends where possible. Staff supported one person to visit his brother who was living in a local care home and people often spent time with their friends in the home or community. The people living in the home regularly met some of the people they had lived with in the past at a local pub. Service users said that they were able to do what they wanted during the day, evening and at weekends and particularly liked the “dinners” and “activities”. Some service users chose to spend time in their room alone whilst others preferred to spend time with staff and the other service users in the lounge or dining room. There were no restrictions about how and where service users spent their time in the home and staff ensured that service users privacy was maintained where possible. Information about the food provided in the home was recorded. A variety of different dishes were provided and there was evidence that people often ate different meals through choice. Records showed that people were supported to prepare and serve meals and lay the table. People were prompted to choose what they ate and to decide how they wanted to spend their time in the home. Records showed that people used public transport, taxicabs and the homes own vehicle to get out and about in the local community. Brandley Ltd. (Orchid House) DS0000062815.V354084.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support was provided to meet people’s personal care needs and to identify and address health care issues. The management of medication was mostly good but some records were not maintained in a consistent manner. EVIDENCE: All of the people living in the home had a key worker. There was some evidence that people were consulted about who they would like to be their key worker. Staff had a good understanding of people’s needs and provided detailed information about peoples preferred routines, likes and dislikes. Records showed that people were supported to visit their GP and to attend hospital appointments. Staff obtained support or advice from other professionals where necessary. Feedback from other health care professionals was mostly positive. People said that staff were usually able to meet people’s individual health care needs and usually had the right skills and experience to support the people living in the home. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 15 Medication was stored securely in a locked cabinet in people’s bedrooms. Records of administration of medicines were good and all medicines were in stock. Records of receipt of medication were variable with information recorded about medication received in the home on one of the two charts seen. See requirement 2. The medication policy and procedure was reviewed and updated in 2006. The procedure did not include adequate information for staff. The procedure must be revised to include information about all aspects of medicines management such as receipt of medication, record keeping arrangements, staff training, competency assessments, adverse reactions and covert administration. There was conflicting information about the storage of medicines in the procedure. See requirement 1. Staff received ‘in house’ medication training. See recommendation 2. There was no written evidence to show that staff were assessed to see if they were competent to administer medication. See requirement 3. Brandley Ltd. (Orchid House) DS0000062815.V354084.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to protect people from abuse and to ensure that complaints and concerns were managed effectively. EVIDENCE: The complaints, suggestions and representations procedure was examined. The procedure included information about the procedure for making a complaint, the timescale for receiving a response and the details of people they could contact if they were not satisfied with the homes response. Information about the local CSCI office was out of date. The procedure acknowledged that there might be a conflict of interest if the director was asked to investigate complaints about his partner, who managed the home. The procedure stated that complaints about the manager might be referred to social services for investigation. The procedure was rather long and may be difficult for people with learning disabilities to understand. The manager said that a pictorial complaints leaflet was being developed to help the people living in the home to understand the procedure. It is recommended that this document be finalised as soon as possible. See recommendation 3. The home had not received any complaints in the period since the last inspection. Staff were aware that concerns or complaints should be logged in the complaints book and referred to the manager or director. Health care professionals said that staff usually responded appropriately when concerns were raised about the service. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 17 The home had policies and procedures in relation to adult protection including a copy of the London Borough of Newham Safeguarding Adults Procedure and a whistle-blowing policy. Staff were aware that they should report allegations of abuse or misconduct to the manager. The money records for two people were examined. The records seen were up to date and were signed by a member of staff and the person that lived in the home. All incoming and outgoing money was recorded and receipts were retained where possible. The cash kept in peoples cash tins corresponded with the balance recorded. Recent purchases included personal clothing, “activities”, CD’s and a trip to the cinema. Staff should record specific information about “activities” in the money records. See recommendation 4. All of the people living in the home had a personal bank account. Bank books were stored safely. Brandley Ltd. (Orchid House) DS0000062815.V354084.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean, comfortable and homely environment for the people using the service and their visitors. The ground floor en suite shower room felt cold. EVIDENCE: Bedrooms were clean tidy and comfortable and personal items such as certificates and photographs were displayed. One person showed the inspector the outfit they wore on their birthday, which was carefully laundered and stored in their wardrobe and another person pointed out his favourite football players from some of the pictures kept in his room. The other parts of the home were clean and tidy and pleasantly decorated. No significant maintenance issues were noted but the lock on the bathroom door was missing and the ground floor en suite shower room felt cold. There was no heating in this room. See requirement 4. Concerns identified during the Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 19 previous inspection about the storage of waste paper bins and a mirror in the lounge had been addressed. Cleaning materials and waste were stored appropriately. Hand washing facilities were good. The refrigerator and freezer temperatures were monitored regularly but some of the temperatures were above the recommended level. Action was taken to address this issue during the inspection and the manager agreed to check that the action by staff was effective. Opened foods were labelled and stored appropriately. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a stable team of well-qualified staff who provide good support for the people using the service. The people living in the home were protected by the homes recruitment practices but some additional checks must be undertaken to ensure that references are genuine. EVIDENCE: There was one member of staff on duty on each daytime shift and a carer slept on the premises during the night. Staff said that, “if ever the need arises and extra staff are needed, then there is always back up available including the manager”. A four weekly duty roster was examined. The roster showed that the people living in the home were supported by staff who were familiar with their needs. The home had not used any temporary staff and had a very stable team of staff. This provided good continuity of care for the people using the service and was identified by one health care professional as one of the homes strengths. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 21 83 of care staff had attained a vocational qualification in care at level two or above. This exceeds the standard set by the Department of Health. Five recruitment files were examined for staff that worked at Orchid and Sunflower House. Adequate information and checks were undertaken in respect of staff that were employed to work in the home but one reference did not include a company stamp or compliment slip. In these circumstances the reference must be verified to confirm that it is genuine. See requirement 5. Training records for individual staff members were examined. The records showed that staff had access to suitable and relevant training sessions such as epilepsy, fire safety and grief and bereavement. Staff were satisfied with training arrangements and said that the sessions they attended helped them to meet peoples individual needs. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 22 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The atmosphere in the home was open and supportive. There were systems in place to identify health and safety issues and to obtain feedback about the quality of care provided in the home. EVIDENCE: The manager was responsible for managing two of the company’s homes. Both homes are located in Ilford and are a short drive away from each other. The manager was assessed by the commission in 2005 and was found to have suitable qualifications and experience to manage a care home for people with a learning disability. The manager has a social work qualification and completed Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 23 the registered managers award in 2006. The manager provided evidence of continuing development and training. Staff said the manager was approachable and always listened to their views. One staff member said the manager was very supportive and “she is always on the end of the phone, if and when the need is there”. There were systems in place for monitoring the quality of care provided in the home and for obtaining feedback about the service. This included health and safety audits, spot checks, unannounced visits, house meetings and satisfaction surveys. One health care professional and one person that lived in the home completed a satisfaction survey in August 2007. The language and layout of the survey for people that lived in the home was rather complicated. To ensure that responses are as independent as possible the manager should consider asking day centre staff to support people to complete the form. Some audits and checks were not carried out regularly. The manager should prepare a quality assurance programme to address this issue. See recommendation 5. Some of the information that was supplied to the commission about health and safety checks was compared against the records kept in the home. The information provided, was accurately recorded and was in accordance with that submitted by the manager to CSCI. Records indicated that fire extinguishers, gas appliances and the mains electricity installation were inspected regularly but there was no evidence that the emergency lighting system was serviced. See requirement 6. Staff also carried out ‘in house’ checks to ensure that the hot water supply was maintained at a suitable temperature and the smoke detectors were working. Staff were able to attend fire safety training sessions and had an opportunity to demonstrate their understanding of the fire procedure during fire drills. The manager had access to an external company for advice and support about health and safety and employment issues. The manager had prepared an annual development plan for the home. The plan identified the need for staff to provide information for the people using the service in a more easily accessible and understandable format. Some staff had attended specialist multi-media training sessions to assist with this work. The home had an accident book but there were no records of any accidents occurring in the period since the last inspection. Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 X Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13 Requirement The Registered Person must ensure that the medication procedure provide guidance and information about all aspects of medication management. The Registered Person must ensure that adequate records are maintained about the receipt of medication. The Registered Person must establish a formal means to assess whether care workers are sufficiently competent in medication administration before being allowed to give medicines. This process must be recorded in the care worker’s training file. The Registered Person must ensure that a lock is fitted to the bathroom door and adequate heating is provided in the ground floor en suite shower room. The Registered Person must ensure that staff references include a company stamp /compliment slip or are verified by the manager. The Registered Person must ensure that the emergency lighting system is serviced DS0000062815.V354084.R01.S.doc Timescale for action 01/02/08 2. YA20 13 11/01/08 3. YA20 13 01/03/08 4. YA24 23 11/01/08 5. YA34 19 01/03/08 6. YA42 23 11/01/08 Brandley Ltd. (Orchid House) Version 5.2 Page 26 regularly. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA20 YA22 Good Practice Recommendations The Registered Person should ensure that records show what progress people are making in meeting their personal goals. The Registered Person should consider obtaining medication training from an external source. The Registered Person should provide a copy of the complaints procedure, in a suitable format for each of the people living in the home. The contact details for the local CSCI office should be updated. The Registered Person should ensure that adequate detail is recorded about the use of personal money. The Registered Person should ensure that satisfaction surveys are provided in a format that the people living in the home can use. The manager should prepare a quality assurance programme. 4. 5. YA23 YA39 Brandley Ltd. (Orchid House) DS0000062815.V354084.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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