Care Home: Orsett House Retirement Home

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What the care home does well There is a very high standard environment which has been consistently upgraded and is well maintained. All areas are bright, pleasant comfortable and well-presented. The Garden/patio areas with summerhouse provide good external facilities. Visitors are warmly received and those spoken with confirmed that they were kept informed about the progress of their relatives. Relaxed, warm, friendly exchanges were observed between all staff and visitors. There are several residents with dementia care needs resulting in high dependency. Some require assistance with all personal care including feeding. Care observed was given individually in a sensitive way by staff. Some needs fluctuate and the aim is to maintain independence where possible.The home is essentially has 2 separate units. In one (smaller) there are residents with low or non-dementia care needs and having lower dependency. In the other there are residents with higher and mixed dependency needs due to dementia. Several people have the propensity to wander in the home and the spacious communal area provides a safe and unrestricted area, although external doors have security to ensure safety. What has improved since the last inspection? A complaint since the last key inspection resulted in a Random Inspection on 28/02/08. Nine requirements were made to change/improve care and practice. These included: residents rising early, inadequate staffing, poor infection control, many falls and inadequate fluids. On this inspection all 9 requirements are found to have been satisfactorily addressed by the home. It has not been easy to change established routines and care practice, but staff have responded well in the areas identified and positive improvements made. What the care home could do better: Provide staff, residents and visitors with greater opportunities to express their views about the home. Improved the quality of recording in the daily records of care provided. Review and update some care plans to ensure they contain the necessary current information to meet identified needs. This applies to some older records but monthly reviews should review all aspects of care including all information in care plans. Unlabelled/non-prescribed creams should be removed from storage areas to ensure single-person use and good infection control. All residents should be weighed monthly as a means of monitoring aspects of health. Where there are concerns about weight loss residents should be weighed weekly to closely monitor their condition. CARE HOMES FOR OLDER PEOPLE Orsett House Retirement Home Station Road Barlaston Stoke On Trent Staffordshire ST12 9DQ Lead Inspector Peter Dawson Key Unannounced Inspection 30th July 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Orsett House Retirement Home Address Station Road Barlaston Stoke On Trent Staffordshire ST12 9DQ 01782 372147 01782 374336 cozier@orsetthouse.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Frederick Cozier Mrs Coral Cozier Mavis Toft Care Home 49 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (49), of places Physical disability over 65 years of age (15) Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2007 Brief Description of the Service: Orsett House is a care home providing care and support for up to 49 older people. The home caters mainly for people with dementia care needs and is also able to provide facilities for people with a physical disability. It is large Victorian style property, situated in the village of Barlaston, Stone, Staffordshire. It has been considerably extended over the years and provides a good quality environment set in extensive attractive gardens with patio areas, summerhouse and peaceful gardens. Access from the house is good with ramped areas and handrails providing a safe garden area. There is a good standard environment which is well maintained. Facilities are good – only 3 bedrooms do not have en-suite facilities and there are assisted bathing facilities located throughout the home. Communal space is good with 4 large lounge areas and two dining areas. The Home is separated into two units; one of which supports the residents with dementia care needs and has a higher staffing ratio and the other people with lower dependency needs. The weekly fees charged at Orsett House are £410. This is included in the Statement of Purpose. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced key inspection was carried out by one inspector on one day from 08.15 – 16:45. An Annual Quality Assurance Assessment (AQAA) was provided prior to the inspection. This is a legal requirement and some information is included in this report. The National Minimum Standards for Older People provided the basis for the inspection of Orsett House. There were 47 people were in residence at the time of the inspection. Six written questionnaires were received by us directly from residents/relatives and three visiting relatives were spoken with during the inspection – these views are also reflected in this report. Most residents were seen and 12 spoken with. The Provider, Manager and staff on duty were also spoken with their views also contained in this report. There was an inspection of the communal areas of the home and a sample of bedrooms were seen. Documentation relating to the inspection process were inspected, including care plans, risk assessments, daily records, medication records, staffing rosters, staff files and other related documents. Many residents were able to express a view about the home and aspects of care, some were not but relatives seen expressed positive opinions about the care provided for their relatives. What the service does well: There is a very high standard environment which has been consistently upgraded and is well maintained. All areas are bright, pleasant comfortable and well-presented. The Garden/patio areas with summerhouse provide good external facilities. Visitors are warmly received and those spoken with confirmed that they were kept informed about the progress of their relatives. Relaxed, warm, friendly exchanges were observed between all staff and visitors. There are several residents with dementia care needs resulting in high dependency. Some require assistance with all personal care including feeding. Care observed was given individually in a sensitive way by staff. Some needs fluctuate and the aim is to maintain independence where possible. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 6 The home is essentially has 2 separate units. In one (smaller) there are residents with low or non-dementia care needs and having lower dependency. In the other there are residents with higher and mixed dependency needs due to dementia. Several people have the propensity to wander in the home and the spacious communal area provides a safe and unrestricted area, although external doors have security to ensure safety. 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 Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 – 5 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes pre-admission procedures ensure the home is suitable for prospective residents. EVIDENCE: There is a Statement of Purpose/Service Users Guide in the home readily available for prospective residents/visitors. It is the usual practice for prospective residents and their visitors to spend time in the home prior to admission to enable them to make an informed choice about the suitability of the home. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 10 Pre admission assessments are carried out in the persons current environment. A pre-admission assessment relating to a recently admitted resident was good and comprehensive. There was also a Care Management assessment provided to the home prior to admission. Several residents are self-funding and a sample of two private contracts with the home were seen, appropriate, signed and in place following admission. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7 – 10 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Further improvements in the recording and review of care plans will ensure residents health and personal care needs will be met. EVIDENCE: One requirement of the last key inspection on 18/05/07 has been met – this was to record reasons for PRN medication being given. Three requirements of the Random Inspection on 28/02/08 have been actioned. – A requirement to complete fluid intake charts accurately could not be reassessed on this visit as there were no residents with charts. A requirement to provide a lockable medication trolley has been met, ensuring Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 12 medication can be secured when transported around the home. This has improved security. The recording of accidents has improved, all are now recorded in care plans but an accident book should be provided to ensure that all accidents are recorded and not just those required to be notified to us under Regulation 37. A recommendation from both the key and random inspections to record rising and retiring times for all residents has been addressed. Although in one record seen it was stated the person did not like rising before 8 am and she was in the lounge at 8.15 am. It is important that these issues are constantly reviewed and form part of the regular monthly reviews of residents. A sample of 4 care plans were seen relating to both short and long-term residents. The care planning format is good and if completed accurately and reviewed gives all required information. The information input is however crucial. Most were good but there were some shortfalls – a record stating “small weight loss over several days, when refuses to eat” was not dated and seemingly not followed up, the person had not been weighed for the past 6 weeks. In relation to a person having a fall with no apparent injury the record stated “please observe” but there was no subsequent entry/comment. If these matters were reviewed on the monthly review cycle they could be followedup/actioned. There was evidence that monthly reviews of care plans had taken place. Three residents with facial bruising were reviewed with the manager from the records seen and whilst dealt with appropriately, identified the need for improved recording in care plans, daily notes and accident documentation referred to above. Daily care notes were fairly brief, often with statements like “a pleasant day” or similar brief statements. It was agreed that this could be improved and may be by means of additional training for staff in the recording of information. There are no pressure wounds in the home at this time. Nutritional assessments are in place to identify those at risk and pressure relieving equipment in place, usually provided by the District Nursing Service as preventive measures. Health needs, diagnosed conditions etc. were well recorded and identifiable in care plans and the home report good relationships with and support from the GP and the District Nursing Service. The medication system was inspected. A new lockable medication trolley for transport around the home has improved the safety of medicines. The receipt, administration and disposal of medication was good. The medication system is inspected monthly by the local Pharmacist who visits and also reviews certain Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 13 medications subject to approval by the GP. medication for residents. This ensures a regular review of Two non-prescribed/unlabelled creams seen in the sluice area must be removed/disposed of. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 –15 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Changes in care routines and practice must be sustained to improve the quality of life for residents. EVIDENCE: A requirement was made at the Random Inspection dated 28/02/08 stating that : There should be a natural waking policy. Rising times must take account of individual resident need and not staff expediency. This related to a situation on that visit when 27 residents were up in the lounge at 7.30 a.m, many having been wakened. This matter has been addressed by a change in routines, practices and staff attitudes towards natural waking and resident choice. - Staff now commence Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 15 getting people up from 7.0 am providing they are awake and wish to rise. Previously 2 staff came on duty at 6.00 am – now 1 arrives for duty at 7.0 a.m. Breakfast and lunch are provided later to allow more flexibility of routines. This has considerably improved the situation – on this visit 20 were up in the lounge areas at 8.30 a.m and there was evidence that residents are now given drinks upon rising, with kettles etc. provided near to the bedroom areas. Recording of rising times is crucial to the concept of natural waking and rising and is referred to in the previous outcomes. Activities are provided by care staff and co-ordinated by an activities worker with up to 16 hours per week provided over 4 days specifically for activities. There are the usual indoor activities and a large, landscaped external garden with patio areas provides opportunities for walking and sitting in a pleasant enclosed safe area. One relative in written feedback said “residents never seem to be taken into the garden during the good weather” although a visitor spoken with during the inspection said that he takes his mother into the garden and summerhouse areas when visiting during the summer and sees other residents there. Minutes of residents meetings held in April and May this year recorded that residents made choices about activities stating they like and would like more music, mobility exercises, gardening, poetry and also entertainment including line-dancing, choir and accordionist. These requests had been included in the planned activities. During the inspection day background/period music was playing in place of the usual TV exposure. Three visitors were seen and expressed satisfaction with the care provided. Two were taking their relatives out for the day, another said he takes his mother for local canal-side walks and said some activities are provided each day – commenting that some visitors may feel that activities are few but they are provided usually in the afternoons and he has visited on Saturday mornings when there has been an organist who visits weekly. The Annual Quality Assurance Assessment (AQAA) completed by the provided states “Staff involvement in social activities has improved”. Residents and visitors spoken with said that they liked the food. The mid-day meal served was well presented and appetising. Choices about food and quantity were evident as staff served the meal. Special diets are provided as required. Everyone was having the same meal and whilst there was not a stated alternative the provider said that they could have an alternative dish. It was agreed that residents should/would not have to ask for alternatives but perhaps a list of alternative choices could be made available and offered to residents. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 16 It was noted that small tables have been provided between seating in the lounge areas to accommodate hot drinks given to residents while seated. This previously presented a potential scalding risk. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints have been addressed by the home when requirements are made to ensure the well-being and protection of residents. EVIDENCE: In written feedback a relative had stated that a formal complaints procedure was not available, but copies of the procedure were posted in the home for residents and visitors and all given a copy of the procedure upon admission. The procedure needs to be updated with contact details for CSCI. No complaints have been received directly by the home since the last inspection. A serious complaint was received and investigated by us by means of a random inspection on 10/02/08. This resulted in 9 requirements being made and is referred to in other areas of this report. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 18 A further complaint was received by us from a relative in November 2007 stating that they had not been informed of an incident of scabies in the home. This was discussed with the provider who had taken all necessary steps and precautions but failed to inform visitors or CSCI under Regulation 37 that this had occurred. A requirement of the last key inspection to refer a matter to the POVA Register for a person dismissed was evidenced at this inspection. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 – 26 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a high standard, well-maintained and safe environment. EVIDENCE: This is a good standard, well maintained environment which meets the National Minimum Standards. The standards of furniture, fittings and décor are high. There has been continued re-investment into the environment over the years. It is well-presented, comfortable and homely. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 20 Standards of cleanliness and hygiene observed during this inspection were high. A sample of bedrooms were seen, all were bright, comfortable, well furnished and well-personalised reflecting the individuality of the person. Only 3 bedrooms do not have en-suite facilities. The external area compliments the interior with a large landscaped garden and patio area which is central to the building, easily accessed and has good seating and facilities including a large summerhouse. This is a safe area residents can use to walk/wander or use with visitors. A recommendation of the last key inspection to provide small tables between seating in the lounge areas has been acted upon, ensuring residents can safely received hot drinks whilst seated. Two requirements arising from the Random Inspection on 28/02/08 have been addressed: Supplies of protective equipment (gloves and aprons) have been made more readily available for staff and adequate supplies of facecloths and wipes to avoid use of other material have also been more readily available. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 - 30 were inspected on this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are now satisfactory. The number of night staff must be maintained to ensure the safety of residents. EVIDENCE: The staffing levels of the home are 7:5:3 over the 24 hour period, this is a necessary and agreed level to meet the needs of a fairly highly dependent group. A requirement was made at the last key inspection to ensure 3 staff were always on duty in the home during the night, as this had not always happened. A further requirement was made at the Random Key Inspection on 28/02/08 only 2 staff were found to be on duty and this was unsafe for 47 people. Staffing rosters and other information were seen on this inspection that indicated that there had been consistently 3 people on duty at night since the Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 22 Random Inspection. Agency staff had been used where necessary. It was impressed upon the provider and manager that this level must always be provided to ensure the safety of residents at night. There had also been occasions when 7 staff had not been on duty on the morning shift and a requirement made to ensure that number was consistently available. Staffing rosters confirmed that this had been maintained since the Random Inspection, again with use of agency staff as needed. The provider stated in the AQAA that over the past 12 months there had been high staff cover on all shifts. This is not correct as stated above. Staff on duty were spoken with and had detailed knowledge of the care needs of residents. Good, friendly, relaxed interactions were observed between residents, staff and visitors. A sample of 2 staff files evidenced that all required information had been obtained prior to employment and that recruitment procedures protected residents. Staff training was not inspected in detail. There has been training since the last inspection in the Safeguarding Vulnerable Adults, staff spoken with were involved in NVQ training and new staff involved in induction training. Staff meetings were said to be held approximately 4 monthly. Only 1 record of a staff meeting held recently was available and showed that around half of the staffing group had attended. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31-33 & 37-38 were inspected on this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Managers have responded positively to address complaints made about the operation of the home. EVIDENCE: The Registered Manager has worked at the home for 20 years and has considerable experience and competence in providing care for this resident group. She is directly involved in care and works on the staffing rota also. She takes a positive lead by example in the home. She has a relaxed and informal Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 24 approach to residents, staff and visitors and works closely with the owners one of whom is also a joint Registered Manager. The home has generally been run in the interests of residents although recent events have indicated that staff expediency rather than resident interest was paramount. Steps have been taken to remedy this. Supervision of staff is carried out by the Manager although records were not seen on this inspection. Some aspects of record keeping in care planning information do need improvement as stated earlier in this report, but other aspects of recording are to a satisfactory standard. Notifications of accidents are now notified to us under Regulation 37 as required in the last key inspection report but they do need to be recorded in the homes accident book as a chronological record. Residents meetings are held but not relatives meetings at this time. The home conducts and annual survey of the views of residents/relatives to feedback upon satisfaction with the service. This commenced in March 2007 and has been repeated this year (38 replied out of 42 questionnaires sent out). The results have not yet been summarised and should be included in the Statement of Purpose when complete. Fire records were not inspected on this visit. The provided said that he had revised the Fire Risk Assessment in July 2007 which had been seen and approved by the Fire Officer. Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X 2 3 Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 12(1) Requirement Ensure all residents are weighed monthly and weekly if there are concerns about weight loss. Timescale for action 31/08/08 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 OP7 OP7 OP9 Good Practice Recommendations Update and review care plans to ensure they contain current information/instructions for meeting needs. Improve the quality of recording in the daily record of care. Unlabelled creams in central storage area must be removed and destroyed. DS0000004988.V368978.R01.S.doc Version 5.2 Page 27 Orsett House Retirement Home 4 OP38 All accidents to residents must be recorded in accident book regardless of outcomes – Schedule 3(3)(j) Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Orsett House Retirement Home DS0000004988.V368978.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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