Care Home: The Orchards

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What the care home does well A good framework is in place for handling referrals and admissions, increasing the likelihood that appropriate admissions will be made. People have their needs assessed and are offered the chance to come to the home and meet the people who live and work there. The buildings are clean, homely and comfortable. People are able to personalise their bedrooms. Specialist adaptations are provided as necessary. Health and safety is generally well managed. People living in the home are offered choices in different ways according to their needs, helping them to feel listened to and in control of their lives. They are supported to lead lifestyles which reflect their needs and interests and to stay in contact with family. A varied and balanced diet is offered which meets people needs and caters for their choices and preferences. People`s personal care needs are appropriately met, with privacy and dignity respected and choices responded to. Healthcare needs are also generally being comprehensively met. Sound arrangements for handling medication are in place, with further improvements planned. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 6People are enabled to say if they are unhappy about something and this is responded to positively. Measures are taken which help to safeguard people from harm and abuse. People feel comfortable and safe with the staff team. Staff are skilled and knowledgeable about the people they support. They generally have access to the training they need. The manager has a good understanding of recruitment and selection procedures, helping to ensure that people using the service are protected and that they have a say in who support them. The home is being well run. The manager has already introduced new ways of working, with more initiatives planned. Good systems for checking the quality of the service are in place, including getting the views of the people living in the home and their representatives. What has improved since the last inspection? The way that medication is handled has improved. There are new ways of working which help to reduce the chance of mistakes being made. Staff meeting have become more regular, helping to ensure that there is good communication in the home. Work has begun on making care planning more person-centred. Health action planning is also starting to be introduced, so that each person`s health needs will be looked at in detail. Many of the documents used in the home have been made more accessible through the use of symbols and pictures. Policies and procedures have been reviewed and updated, providing a thorough framework for the way that the home operates. New systems for checking and improving the quality of the service have been introduced. What the care home could do better: Further work is needed to ensure that care plans are up to date and describe how people`s needs will be met. Consideration also needs to be given to whether risk assessments are in place where necessary and that they are up to date. Some aspects of healthcare need attention to make sure that people are being accessing routine services and/or that there is a plan of care in place.The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 7Staff training and supervision arrangements need to improve in order that people have the support they need for their roles and responsibilities. Some requirements have been repeated from the previous inspection. However, the manager was relatively new in post and there was evidence that new ideas were being introduced to make the necessary improvements. Progress will be checked during future inspections. The manager agreed to inform us when requirements had been met. CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 The Orchards Stowfield Lower Lydbrook Glos GL17 9PD Lead Inspector Mr Richard Leech 20 & 21st December th Key Unannounced Inspection 10:20 – 20:00 & 10:10 – 16:00 The Orchards DS0000016522.V354978.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 The Orchards DS0000016522.V354978.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 and 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. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Orchards Address Stowfield Lower Lydbrook Glos GL17 9PD 01594 860493 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) Donna@orchard-trust.org.uk www.orchard-trust.org.uk The Orchard Trust Care Home 17 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (17), Physical disability (17), of places Physical disability over 65 years of age (17) The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The LD or LD(E) category must apply to all service users in the home, but they may also have needs under PD & PD(E) One place is registered for the category Sensory Impairment with Learning Disability 8th March 2007 Date of last inspection Brief Description of the Service: The Orchards is run by the Orchard Trust and provides two different types of accommodation on the same site. The main unit is known as Offas Dyke and consists of three interlinked four-bedroom bungalows and two single rooms, one with en suite facilities. A couple of hundred meters away is a semidetached house known as 1, The Orchards, which can accommodate three people. On the site there is also the main office for The Orchard Trust and a continuing education centre called The Barn, which is run in conjunction with a local college. This offers a wide range of activities that people living at The Orchards may attend. There is also a large sensory garden and a smallholding with animals on the site. Offas Dyke provides accommodation for people with a learning disability who may have a physical disability and a need for a high degree of personal care. People living a 1 The Orchards are more independent. The site is situated close to the village of Lower Lydbrook, in a rural setting on the edge of the Forest of Dean. Up to date information about fees was not obtained during this inspection. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the site visits the manager completed an Annual Quality Assurance Assessment (AQAA), providing information about how the home operates and plans for the future. Survey forms were also distributed to some of the people with an interest in the home such as family members and health & social care professionals. Some people living in the home completed survey forms. Two visits were made to the home. These took place on a Thursday and Friday, with the first visit lasting into early evening. Most of the people living in Offas Dyke and The Orchards were met, along with many of the staff team. The manager was also present for most of the time during the visits. A new manager was in post, the previous manager having moved to another of the Trust’s homes. The new manager joined the team in August 2007, having also previously managed another of the Trust’s homes. During the visits to the home various documents were checked including examples of care plans, risk assessments, medication charts, daily records, health and safety information and staffing files. Some general observation of life in the home took place and the premises were inspected. What the service does well: A good framework is in place for handling referrals and admissions, increasing the likelihood that appropriate admissions will be made. People have their needs assessed and are offered the chance to come to the home and meet the people who live and work there. The buildings are clean, homely and comfortable. People are able to personalise their bedrooms. Specialist adaptations are provided as necessary. Health and safety is generally well managed. People living in the home are offered choices in different ways according to their needs, helping them to feel listened to and in control of their lives. They are supported to lead lifestyles which reflect their needs and interests and to stay in contact with family. A varied and balanced diet is offered which meets people needs and caters for their choices and preferences. People’s personal care needs are appropriately met, with privacy and dignity respected and choices responded to. Healthcare needs are also generally being comprehensively met. Sound arrangements for handling medication are in place, with further improvements planned. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 6 People are enabled to say if they are unhappy about something and this is responded to positively. Measures are taken which help to safeguard people from harm and abuse. People feel comfortable and safe with the staff team. Staff are skilled and knowledgeable about the people they support. They generally have access to the training they need. The manager has a good understanding of recruitment and selection procedures, helping to ensure that people using the service are protected and that they have a say in who support them. The home is being well run. The manager has already introduced new ways of working, with more initiatives planned. Good systems for checking the quality of the service are in place, including getting the views of the people living in the home and their representatives. What has improved since the last inspection? What they could do better: Further work is needed to ensure that care plans are up to date and describe how people’s needs will be met. Consideration also needs to be given to whether risk assessments are in place where necessary and that they are up to date. Some aspects of healthcare need attention to make sure that people are being accessing routine services and/or that there is a plan of care in place. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 7 Staff training and supervision arrangements need to improve in order that people have the support they need for their roles and responsibilities. Some requirements have been repeated from the previous inspection. However, the manager was relatively new in post and there was evidence that new ideas were being introduced to make the necessary improvements. Progress will be checked during future inspections. The manager agreed to inform us when requirements had been met. 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. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A good framework is in place for handling referrals and admissions, increasing the likelihood that appropriate admissions will be made. EVIDENCE: This standard was assessed as met during the last visit in March 2007, with appropriate procedures found to have been followed in respect of recent admissions. Since then there had been no new admissions. New policies dated September 2007 had been written covering different aspects of referral and admission. These included consideration of assessing The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 10 and meeting needs as well as describing the approach to introductory visits and trial periods. In the AQAA the manager gave an overview of the approach to referral and admissions, providing further evidence of appropriate procedures and practices being in place. The Statement of Purpose and Service Users Guide were not checked in detail, although it was noted that the documents had been reviewed in November 2007. At the time considerable effort was going into making the Service Users Guide a more accessible document. This is good practice. The service was considering raising the percentage of higher rate DLA (Disability Living Allowance) taken towards transport costs from 35 to 100 at some point in 2008. There was a discussion about the consultation and notification process and also of the need for amendment of documents including the Service Users Guide. There would also need to be a clear audit trail such that it would be possible to track the money and what it had been spent on. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Further work is needed to ensure that care plans are up to date and describe how people’s needs are to be met. People in the home are empowered to make decisions in their daily lives, helping them to feel valued and in control of their lives. A more thorough approach to risk assessment and review would help to further promote people’s safety and wellbeing. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 12 EVIDENCE: The manager and staff reported that work was underway to review and update care plans and to make them more person-centred. Liaison was taking place with the Community Learning Disability Team and Social Services about people’s care plans. Care planning files for two people were checked in detail during the visits. The first person’s care planning file included information about their background, some basic contact and biographical details, comments on strengths and needs and a description of some of the person’s routines. A series of numbered care plans described how the person’s needs were to be met in key areas such as mobility, activities, health, making choices, finances and social/emotional needs. Although some of the information was recent such as notes on communication and healthcare, in most cases there was no documented evidence of review since October 2005. Also, some of the care plans could not be said to describe how the person’s needs were to be met. For example, the plan about management of finances was that, “[service user] requires care staff to use his money in ways which only benefit him”. A draft person-centred plan for the person was seen providing evidence that the care plans were beginning to be reviewed and updated, incorporating changes and attempting to better reflect the person’s wishes and preferences. The second person’s care planning file also included basic biographical information and contacts. The contact sheet was dated February 2002 and was unclear, with crossings out. This should be rewritten. The file also included guidelines about mobility, diet and health. However, no other care plans were seen, resulting in no information about how needs in areas such as activities, general personal care, social and emotional needs, communication and mental health would be met. It transpired that the majority of the person’s care plans had been removed from the file whilst some work took place on creating a person-centred care plan, although the plans were still accessible in a filing cabinet. Much of the removed material was still current (e.g. documents dated November and December 2007), although the majority of care plans had not been updated since November 2005. It was agreed that the service should always ensure that care plans are not archived until new care plans which fully describe how the person’s needs will be met are in place. Protocols and guideline around different aspects of healthcare were seen on care planning files, created by or in conjunction with relevant professionals. A policy was seen about person-centred planning, providing a framework for the introduction of a more person-centred care planning system. Policies were also seen covering areas such as decision-making. Restrictions and limitations were seen to be documented, for example, in relation to areas of the home not accessible to the people living there for health and safety reasons. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 13 Observation of life in the home along with discussion with staff provided evidence that people were being offered choices in their day-to-day life as far as possible. This included around activities, menus, times for getting up and going to bed, clothing and where and with whom they spent time. Some of the people living in the home confirmed that they were asked about choices, and that they were able to make decisions about different aspects of their lives and were listened to. During the visits one person was expressing unhappiness about some issues. The service was seen to respond in a skilful and sensitive manner to ascertain what was troubling the person and to then offer the option of accommodation elsewhere on the site. One person was seen to ask for a drink and a snack. Staff immediately responded. The manager reported that the team was trying to promote total communication within the home. Work was taking place on making different documents more accessible. Rick assessments for two people were checked. One person had risk assessments covering areas such as mobility, transportation and healthcare. However, in many cases there was no evidence of recent review, with the last documented reviews taking place in July 2005 or even September 2004. There also appeared to some confusion about the headings and what was being assessed, with staff writing about ways of managing the risk in the section which called for a description of the nature of the risk. The manager said that the risk assessment format was being reviewed and simplified. There were also plans for risk assessments to be the subject of periodic audit as part of quality assurance. These steps may help with the issues described above. The second person’s risk assessments consisted of consideration of just two areas; smoking and the use of bedsides. The manager felt that there were no other areas of significant risk that needed to be assessed. Nonetheless consideration should be given as to whether the significant risks that the person encounters in daily life have been documented and whether there are any other areas requiring assessment. A policy dated September 2007 was seen covering risk taking and risk assessment/management. This included that there would be a formal risk assessment for each situation which may carry a significant risk. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 15 Appropriate support is provided for people to take part in activities which reflect their needs and interests both in the home and community. People are also supported to maintain and develop contact with important people in their lives. People’s rights are recognised and independence is promoted, enhancing their self-worth and autonomy. A varied and balanced diet is provided, enhancing the health and quality of life of the people living in the home. Their needs and preferences are catered for. EVIDENCE: Policies were seen dated September 2007 covering areas such as social inclusion and community links. During the visits people were seen going on trips to local shops and hairdressers, playing pool and listening to music. There was also a trip to a swimming pool. Some people had gone to stay with family. ‘The Barn’ (an onsite learning centre run jointly with a college) had closed for the Christmas break, but staff reported that this was a well-used and valuable resource. Staff also described the people living in the home helping to look after the animals and enjoying seeing them. As noted, there was information in care planning files about people’s activities. Daily records provided evidence of people being supported to take part in a wide range of activities in the home, on site and in the wider community according to their individual needs and interests. In some cases health was impacting on the person’s motivation. Discussion provided evidence of the team drawing upon support from relevant agencies in an attempt to address the underlying issues. There was some feedback about a lack of activities outside of the home for certain people. The manager said that this had been raised in recent staff meetings and that consideration was being given to how to increase the range of opportunities. It was reported that the home had a number of different vehicles available as well as dedicated drivers. Another driver/maintenance person was being recruited at the time due to staff turnover. There was evidence in daily records about people in the home being supported to stay in contact with family and friends. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 16 The service has a policy covering relationships and sexuality dated September 2007. This included coverage of areas such as people’s rights, safeguarding from abuse and exploitation, and of education where appropriate. People were seen moving freely around the home, or being assisted to move around in accordance with their wishes as far as is possible to ascertain. Discussion, observation and daily records provided evidence of flexible and individual routines operating in the home. Notes indicated that people were involved in the running of the home, for example, helping with cooking. One person was also reported to have a recycling job within the home, providing them with some income. People spoken to expressed satisfaction with the food they were offered and confirmed that they had choices over what they ate. One person said that their special dietary need was catered for. People were seen being offered choices about what they ate throughout the visits, and being offered snacks. Menus provided evidence of variety and balance. Staff confirmed that food was generally freshly prepared and expressed confidence that people’s nutritional needs were being met. Individual food records were being kept. People were seen being supported to eat as necessary, with adapted plates and cutlery if required. In a written survey form one person answered the question ‘what’s good about living at your home’ by saying, ”doing my own washing, ironing, cooking…going out a lot”. Another person answered, “nice…cooking, gardening, going out, holidays’. Feedback from family members included that the staff had been ‘absolutely fantastic’ during a recent period of poor health for their relative and that the care ‘could not be better’. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are appropriately met, enhancing their wellbeing and self-esteem. Healthcare needs are also generally being comprehensively met, although there are some areas which could be developed in order to promote optimal health. Sound arrangements for handling medication (with further improvements planned) help to ensure that people are protected and stay well. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 18 EVIDENCE: People were seen being supported with their personal care needs in a sensitive manner. Staff were observed to be very conscious of protecting people’s privacy and dignity. Discussion with staff also provided evidence of this awareness, with care workers giving examples of how they promoted privacy and dignity, as well as describing how they developed people’s independence and responding to preferences around delivery of personal care. One person was seen to request that a particular member of staff assisted them with an aspect of their care. This was immediately respected. An up to date policy was seen around personal care covering issues such as dignity, gender of carers, choices and appearance. Healthcare notes for two people were checked in detail. Both sets of notes provided evidence of people being supported to access a wide range of healthcare services, including receiving highly specialist support according to their needs. There was evidence of the involvement of the Community Learning Disability Team in people’s care, and the home being proactive in liaising with the team when issues arose. Records were seen of more routine appointments and checks. These generally provided evidence that people were accessing routine services. However, one person’s last record of having their eyes checked was in October 2004, with no evidence of any follow up since (although the letter had referred to follow up a year later). There was no entry for when the person last had a dental check. Staff reported that the person became distressed when attending such appointments to the point where they had little value. If this is the case then there should at least be a care plan, including guidance from professionals, describing areas such as how oral and ocular health is monitored/promoted, possible signs of pain/deterioration and what action staff should take if intervention appears to be necessary. It was reported that health action planning was being introduced in parallel to person-centred planning. This should help to ensure that issues such as the above are considered and the person’s support needs documented. A second person’s notes indicated that they were receiving regular routine checks. Some health action plans were in place about specific health issues, although these were undated. Discussion with staff provided evidence that some recommendations from a specialist were generally being put into practice. However, it had been recommended that one person use toothpaste suitable for sensitive gums, but this was not being done. This was brought to staff’s attention. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 19 Records were seen of areas such as people’s weights, fluid intake, seizures, continence and personal care where appropriate. Arrangements for the handling of medication were checked. New policies covering this area were seen dated September 2007. It was reported that nobody in the home was self-administering medication. Administration records for two people living in the home were checked and appeared to be in order. Storage arrangements were also satisfactory, although internal and external preparations were not separated. It was accepted that this was not possible at the time due to the constraints of the cabinet and trolley. The deputy manager reported that a new medication trolley was hopefully going to be obtained in the near future. A pharmacist from the supplying pharmacy had recently visited the home and conducted a check of the systems for handling medication. Their report was seen. It was hoped that this would become regular and serve as a further check on the systems in place. The home operates a system of only senior staff administering medication. It was reported that all seniors had in-depth training about the handling of medication. Training records and discussion with staff provided further evidence for this. This was reported to work well. However, there were plans for all care staff to receive training in medication and to then take on a doublechecking role in order to reduce the likelihood of errors being made. A communication book for senior staff was seen to include important information about medication such as changes to the medication regime. Protocols for medication given as required (‘PRN’) were seen. These were clear and sufficiently detailed. It was reported that there were a few more to complete in respect of external preparations only. The arrangements for transporting medication to The Barn were discussed. A protocol had been written about this. This had been a requirement from the last report, although it was reported that this practice was in any case no longer necessary. The deputy manager described the system for ordering, booking in and returning medication. This included various checks to ensure that prescriptions were correct and that adequate stock levels were maintained. A monthly audit takes place, an example of which was seen. Some points were noted as needing attention: • Records were in place for recording medication taken off site. However, staff were not always logging the return of the medication on site. DS0000016522.V354978.R01.S.doc Version 5.2 Page 20 The Orchards • • • A system of audits of paracetamol was in place but this had last been done in September 2007. Counter signing of medication booked in was generally seen to happen (as evidenced on administration records) but had not been done for the current month’s supply. Some handwritten entries on the chart were not counter-signed. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place which support people to express dissatisfaction, helping them to feel listened to. Measures are taken which help to safeguard people from harm and abuse, although some aspects of the handling of finances could be tightened up to protect people’s interests. EVIDENCE: The service has a complaints procedure in written and symbol form, including details about the timescales and stages as well as contact information for the CSCI. The Statement of Purpose also included information about how to complain. Surveys and discussion with some of the people living in the home provided evidence that people felt able to speak up if they were unhappy, and that they felt listened to when they did. Staff described how they recognised and The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 22 responded to indications of dissatisfaction from people who did not have verbal communication. One formal complaint had been received since the previous inspection. Copies of the documentation had been sent to us, providing evidence that the issue had been appropriately responded to. As noted, one person was voicing discontent during the visits and this was seen to be responded to. A policy about adult protection was seen. This was dated September 2007 and was very comprehensive, including definitions of abuse, staff roles and responsibilities and the involvement of other agencies. Policies were also seen covering areas such as physical intervention. Staff reported that there was no restrictive physical intervention practiced in the home. A policy about whistle blowing was also seen, dated September 2007. People living in the home reported feeling safe and trusting the staff. Discussion with staff and training records provided evidence that team members attended training about adult protection about every two years. Staff spoken with said that they would report any concerns they had and expressed confidence in the systems for handling these issues. Arrangements for handling people’s money were checked. These appeared to be generally in order, although the following was noted: • An entry for one person on 17/12/07 stated that £100 had been loaned from the Trust. It was reported that in fact they had been loaned £40, and that £60 of the money coming in was theirs (held in a different location). Although there was a slip which stated that the loan was £40 and therefore this error on the entry would probably not have resulted in the person losing out, care should be taken to ensure that such entries are accurate. A loyalty card for a store had been used, as evidenced on some supermarket receipts. There was some uncertainty as to who this belonged to. This should be checked. If staff are using their own cards then this practice should cease. A slip indicated that £5 of one person’s money had been taken out on 07/12/07 (two weeks earlier). The money was still off-site. Although accounted for, such instances should be followed up so that people’s money is not left off site in this way for unnecessarily long periods. Spot checks were taking place on totals, but it was agreed that these should be made more frequent. • • • The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A clean, homely and comfortable environment is provided, promoting the quality of life of the people living in the home. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 24 EVIDENCE: The building is of unique design and is set in substantial grounds with views of the surrounding countryside. All communal areas and most of the bedrooms were checked. The home had been brightly and attractively decorated for Christmas. The home was seen to be spacious, light and clean throughout. Bedrooms were personalised and people spoken with indicated that they liked their rooms and found them to be warm and comfortable. Some bedrooms had entertainment systems and sensory equipment. Specialist aids and adaptations were provided throughout the home in accordance with people’s needs. Some bedrooms had recently been extended by building around the doors that open out to the patio areas. This has given wheelchair users considerably more space in their bedrooms. An extension had also recently been completed to one of the bungalows creating a large sitting/sensory room. The home has dedicated maintenance staff. Documentary evidence was seen of a rolling maintenance and redecoration programme. There were also maintenance logs, with evidence of issues being quickly attended to. Some work was taking place to redesign bathrooms so that they better suited people’s needs. It was confirmed that an occupational therapist had been involved in the design. The home has under-floor heating, avoiding the need for radiators. Maintenance books provided evidence of necessary work being promptly undertaken when this had recently malfunctioned. Staff spoken with commented on the homely atmosphere, enhanced by dividing the main house into three different ‘bungalows’. Some underpinning work was due to take place on the cottage (The Orchards). This was planned for January and accommodation had been booked for a couple of weeks for the people living there. The deputy manager reported that a hydrotherapy pool was going to be built on site. It was agreed that this would be a tremendous asset to the people living there and potentially to the wider community. A sanitary bin was missing its lid. This will need to be found, or the unit replaced. Staff described the infection control measures in place and the protective equipment available. Policies were seen covering cleanliness and infection control. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Support is provided by a skilled team who generally have access to appropriate training, helping to ensure that people’s needs are met. The manager has a sound understanding of recruitment and selection procedures, helping to ensure that people using the service are protected and that they have say in who support them. Staff supervision arrangements need to improve in order that people have the support they need for their roles and responsibilities. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 26 EVIDENCE: Staff spoken with were knowledgeable about the needs and conditions of the people they supported. Interactions were seen to be warm, respectful and professional, with people’s needs and wishes being attended to. The manager and staff confirmed that all team members are provided with copies of the General Social Care Council code of practice. Policies were seen about staffing matters. This included a commitment to at least 50 of the staff group attaining NVQ in health and social care to level 2 or above. Information supplied in the AQAA indicated that about a quarter of the staff had attained this at the time, with more staff working towards the qualification. The manager said that there were plans to increase this figure. Communication books within the bungalows as well as a general communication book were seen, providing evidence of a good flow of communication. Staff confirmed that handovers took place between each shift and that key information was conveyed. Minutes were seen of some recent staff meetings and one took place on the day of the visit. A seniors’ meeting took place on the second day of the visit to the service. Staff confirmed that meetings took place regularly. Information about recruitment and selection procedures was provided in the AQAA. The manager described the process, including plans for increasing the involvement of the people living in the home. Policies and procedures were seen covering different aspects of recruitment and selection dated September 2007. Staff were starting work on a PoVA-first basis. It was explained that this was due to criminal records bureau checks taking a long time to come back. This was accepted but with the proviso that this remains exceptional practice rather than becoming routine. Confirmation of PoVA-first checks being returned clear was seen on the staffing files looked at. Staffing files for some people recently recruited were checked. These appeared to be in order. Some references were personal rather than professional. The reasons for this were outlined. This was accepted, on the understanding that wherever possible professional references should be sought in preference to personal ones. The Trust has a training coordinator. Training records for four staff were sampled. These indicated that some people were overdue for training or refresher input in areas such as food hygiene, first aid, fire safety and moving & handling. The manager had put in place a system for checking what training The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 27 was due. Records were seen providing evidence that the manager had identified where the shortfalls were and was taking action to address them. This area will be revisited during future inspections to check on progress. Discussion with staff along with records showed that specialist training was also being accessed. This included input around use of the PEG tube, supervision training, signing, challenging behaviour, continence, diabetes, record-keeping, infection control, leadership and epilepsy. Staff generally felt satisfied with their training. Some people felt that there could be more input about autism. There were also discussions about whether there may be benefits to staff in having training around other areas specific to people’s needs such as mental health issues and pressure care. The majority of staff had also not yet had any training about the Mental Capacity Act 2005. All staff were seen to have personal development plans with comprehensive training records. Records along with discussion with staff provided evidence of a comprehensive induction programme which includes in-house work, as well as the Learning Disability Award Framework (now Learning Disability Qualifications) induction. Staff spoken with felt satisfied with their induction programmes. There was discussion with staff about supervision and support. People generally felt well supported. The management structure was reported to be clear and the senior team accessible and approachable. A 24-hour on-call system operates, the rota for which was seen. The most recent three supervision dates for four staff were checked. The frequency was variable, but in one case amounted to a meeting every six months. The most recent recorded supervision dates for the four staff were in June, July or August 2007. Some staff spoken with confirmed that they were not having one to one supervision as often as they would like. The manager was aware of this shortfall and said that it would be discussed at a forthcoming meeting of the senior team. A new system for monitoring that supervision meetings were taking place at appropriate intervals was about to be introduced. The manager said that she would be auditing this to ensure that they took place. Through staff feedback a comment was made about the need to recognise, value and thank staff more. During the visit to the site staff were seen to be given wine and chocolates as a token of appreciation and for Christmas. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 29 The home is being well run, promoting positive outcomes for the people living there. Good systems for checking the quality of the service are in place, with further initiatives planned, helping to drive up the standard of care and to give the people living in the home a voice. Health and safety is generally well managed, promoting people’s wellbeing, although some areas of practice could be improved. EVIDENCE: The manager has attained the Registered Manager’s Award as well as NVQ level 4 in care. She has over 20 years of experience in the field of learning disability and has previously managed another of the Trust’s services. At the time of the visits she was applying for registration. In the staff room some team objectives were displayed, with a distinction made between those attained and those still being worked towards. This was accompanied by an action plan, also on display. The AQAA was completed very thoroughly, providing much information about the home’s current operation and future plans. Staff spoken with felt that the home was being well run. People talked about the new ideas being introduced by the manager. Comments included that she was focussed, driven, approachable and straightforward in style, and that the she had high standards. Senior staff spoken with were clear about their role. Examples of reports made under Regulation 26 were seen. These were thorough and taking place every month. A policy was seen on quality management dated September 2007. It was reported that a new quality assurance process would begin from January 2008. This would consist of checklists based around the National Minimum Standards. These audits were planned to take place about once every three months. In addition, monthly spot checks of finances and medication were also planned. These initiatives were in addition to routine Regulation 26 visits. The manager said that she was looking at increasing the involvement of the people living in the home in the management of the service. A User Involvement Group was planned, although this was at an early stage. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 30 The manager and staff described how the people living in the home were consulted on a daily basis, for example around menus, activities and décor. Discussion and observation provided further evidence for this. The manager also described a new system of audits to be conducted by senior staff, including sampling care plans and risk assessments. A questionnaire was seen for relatives. These were to be used as part of a survey during 2008, to gain feedback as part of the home’s quality assurance systems. A survey was also being designed for the people living in the home. This had been made more accessible thought the use of symbols. Staff meetings were seen to be taking place more regularly, also operating as a source of feedback. Staff said that they did training in health and safety and reported having no health and safety concerns. A health and safety audit by an external consultant had recently taken place throughout the Trust. One finding had been that the fire risk assessment and staff training in fire safety would benefit from review. It was also stated that the consultants would be assisting the service with general risk assessments, legionella control, manual handling assessments, and other aspects of health and safety. Documentary evidence was seen of routine checks taking place and of prompt action being taken when issues were identified, for example with faulty equipment. However, routine testing of fire safety systems appeared to have slipped recently. According to records emergency lighting had last been tested on 23/10/07. The last two tests of fire alarms had been on 12/10/07 and 01/11/07, although it was thought that there may have been more (unrecorded) tests. The most recent recorded fire drill had been on 08/08/07. Some hot water temperatures recorded in December 2007 were seen to be quite high (over 44°C), including in communal areas potentially accessible to people living in the home. The manager said that this had been noted and action taken. It was suggested that water temperatures be checked again before the monthly test became due in order to check that the remedial action had been successful. Information was seen in the bungalows about what to do in an emergency, for example during loss of power. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 31 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 x 39 3 40 x 41 x 42 2 43 x 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Orchards Score 3 2 3 x DS0000016522.V354978.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 (1) & (2) Requirement Care plans must describe how people’s needs in respect of health and welfare are to be met. Keep care plans under review and, where appropriate, revise them. Risk assessments must be reviewed regularly and amended when necessary. Timescale of 31/05/07 not met. Ensure that people receive appropriate routine healthcare. In cases where this is assessed as not being possible ensure that there is a care plan which describes how that aspect of the person’s healthcare needs are monitored and their health promoted (e.g. for oral health). Ensure that all sanitary bins have lids. Ensure that all staff have training appropriate to the work performed. Recorded supervision sessions must be provided regularly. Timescale of 31/07/07 not met. DS0000016522.V354978.R01.S.doc Timescale for action 30/04/08 2 YA9 12 (1) a 13 (4) 30/04/08 3 YA19 12 (1) a. 17 (1) a. Sch 3 (3) (m) 30/03/08 4 5 6 YA30 YA35 YA42 13 (4) 18 (1) c (i) 18 (2) 31/01/08 31/05/08 31/03/08 The Orchards Version 5.2 Page 33 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Care plans should not be archived until new care plans which fully describe how the person’s needs will be met are in place. Continue work on developing and implementing more person-centred care plans. Rewrite information in care planning files which is becoming difficult to read due to handwritten additions and crossings out. Ensure that all significant areas of risk that each person encounters in their day to day life have been appropriately risk assessed and, where necessary, a risk management plan put in place. Ensure that all documents are dated. Continue to implement health action planning. Address the issues noted in the text about medication (see four bullet points). Address the points noted in the text about the handling of people’s finances. Consider whether there may be benefits to staff in having training around other areas specific to people’s needs such as mental health issues, autism or pressure care/tissue viability. All staff should also have some training/input about the Mental Capacity Act 2005. It is strongly recommended that testing of the fire systems take plans more frequently (with reference to testing of alarms and emergency lighting). Fire drills should also take place on a more frequent basis. Record all tests and drills. 2 YA9 3 4 5 6 YA19 YA20 YA23 YA35 7 YA42 The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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. The Orchards DS0000016522.V354978.R01.S.doc Version 5.2 Page 35 - 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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