Care Home: The Orchards

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What the care home does well All the questionnaires showed that people are generally satisfied with the care and support they receive. One person said that `The manager will listen to you and help you anytime`. The home is well managed and run in the best interests of the people who live there. Pre-admission assessments are thorough and make sure the home can meet people`s needs.The staff understand the needs and preferences of all the people who live at the home. People`s health is looked after and the staff have the skills and experience they need to do this. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. The medicines administration procedure is safe and accurate. There is good and friendly interaction between the people who live at the home and the staff. There are enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. People said they enjoy their meals and there were drinks offered throughout the day. The cook is aware of people`s dietary needs and preferences. The kitchen and the rest of the house is clean, safe and well maintained. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. What has improved since the last inspection? All the requirements we made at the last key inspection have been met. A medicines trolley has been bought, so that medicines can be stored and administered more safely. A `brought forward` system has been introduced so that all medicines the home has in stock are properly accounted for. All medication is accurately booked in when it is delivered to the home. Senior night staff have now had medicines administration training, so that they can administer medicines safely. All new staff have a Criminal Records Bureau (CRB) check before they start work at the home. The registered provider is now completing monthly reports on the home, to confirm that they are up to date with the way the home is being run. The acting manager has started to improve the care plans, to better reflect the individual`s care and support needs. Staff are now having regular one to one supervision with their line manager. What the care home could do better: The Deputy Manager has been managing the home since January 2008 and now needs to proceed with her application to be registered as the manager. The work to improve the care planning records needs to continue, in order to make sure the plans are clear and easy for staff to follow and to make sure they fully reflect people`s needs. The risk assessments need more work, to both assess potential or actual risks and to put plans in place showing how risks can be minimised. Wherever possible, all the care plans need to be signed to confirm that people and/or their relatives have been consulted. One of the radiators in the dining room still needs to have a protective cover fitted, to protect people from harm when it is hot. The entrance hall, the hallways and stairways would benefit from being redecorated in order to make the home fresher and more attractive. The areas near the lift need to be re-decorated, as there is bare plaster on the walls. Remedial building work needs to be completed near the lift shaft on both floors, as the new skirting boards do not match the existing ones and some cracks have developed in the nearby walls and cornices. The staff who use the room where the washing machine and sluice are installed would benefit from having an extractor system fitted. The acting manager needs to make staff aware of the potential dangers of leaving cleaning chemicals in unsecured areas of the home. CARE HOMES FOR OLDER PEOPLE The Orchards 1 Wilmer Drive Heaton Bradford West Yorkshire BD9 4AR Lead Inspector Liz Cuddington Key Unannounced Inspection 30th July 2008 10:40 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 The Orchards DS0000001167.V369203.R02.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. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Orchards Address 1 Wilmer Drive Heaton Bradford West Yorkshire BD9 4AR 01274 547086 01274 548776 orchardcare@btconnect.com 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) Baybury Limited Mrs Susan Davies Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (19), of places Physical disability over 65 years of age (2) The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2007 Brief Description of the Service: The Orchards is a detached property set in its own grounds. It is located near Lister Park and close to local shops, churches and bus routes. Accommodation is provided on the ground, first and second floors. The majority of bedrooms are single rooms. A passenger lift provides access to the first and second floors. People using the service regularly use the well-kept garden but access is restricted, as steps have to be negotiated at both entrances to the home. The providers have plans to make a ramp to the side entrance. The home is registered predominately for older people. A small number of people may have mental health needs and/or physical disabilities. The current weekly charges range from £340 - £374.00. Additional charges are made for personal expenses including hairdressing, chiropody and newspapers. The Orchards DS0000001167.V369203.R02.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. The purpose of this inspection was to assess the quality of the care and support received by the people who live at The Orchards. The visit to the home was carried out over one day by one inspector. The last key inspection was in August 2007. Since the last key inspection no complaints or concerns have been made to us about the home. Since our last inspection visit the registered manager has left; the Deputy Manager and the Registered Provider are currently running the home. The methods used to gather information included conversations with the people living at the home, their relatives and the staff, as well as looking at care plans and examining other records. We received the home’s self-assessment questionnaire before the inspection visit. We also received questionnaires from people who live at the home, staff and healthcare professionals. These questionnaires give us a lot of useful information about the home and help us plan the visit. We would like to thank the people who live at the home, their relatives and the staff, for their welcome and hospitality and for taking the time to talk and share their views during the visit. What the service does well: All the questionnaires showed that people are generally satisfied with the care and support they receive. One person said that ‘The manager will listen to you and help you anytime’. The home is well managed and run in the best interests of the people who live there. Pre-admission assessments are thorough and make sure the home can meet people’s needs. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 6 The staff understand the needs and preferences of all the people who live at the home. People’s health is looked after and the staff have the skills and experience they need to do this. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. The medicines administration procedure is safe and accurate. There is good and friendly interaction between the people who live at the home and the staff. There are enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. People said they enjoy their meals and there were drinks offered throughout the day. The cook is aware of people’s dietary needs and preferences. The kitchen and the rest of the house is clean, safe and well maintained. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. What has improved since the last inspection? All the requirements we made at the last key inspection have been met. A medicines trolley has been bought, so that medicines can be stored and administered more safely. A ‘brought forward’ system has been introduced so that all medicines the home has in stock are properly accounted for. All medication is accurately booked in when it is delivered to the home. Senior night staff have now had medicines administration training, so that they can administer medicines safely. All new staff have a Criminal Records Bureau (CRB) check before they start work at the home. The registered provider is now completing monthly reports on the home, to confirm that they are up to date with the way the home is being run. The acting manager has started to improve the care plans, to better reflect the individual’s care and support needs. Staff are now having regular one to one supervision with their line manager. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Orchards DS0000001167.V369203.R02.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 The Orchards DS0000001167.V369203.R02.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): 3 Standard 6 does not apply People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People are given enough information about the home before deciding to move in, and they also receive a contract. Where possible the home encourages people and their families to visit the home and talk to the people who already live at the home and their relatives. The home invites them to come and spend time at the home, before reaching a decision. This means that the home can get to know the person’s needs and also the individual and their relatives have the information they need to help them make such an important decision. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 10 If this is not possible, a senior member of staff visits people in their own home or in hospital to carry out an assessment and make sure the home can meet their needs before offering a place. The care plans included the pre-admission assessments completed by the home and Social Services, where this applies. This assessment forms the basis for the person’s individual plan of care and support. The Orchards DS0000001167.V369203.R02.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): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and healthcare needs are met. People are protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: People receive the medical and healthcare support they need and any concerns about people’s health are followed up. People said the care is good and the staff are kind and helpful. Relatives said they are very happy with the care the home provides and feel that the staff understand their relatives’ needs. One healthcare professional said ‘I am satisfied with the care given to my patients’. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 12 One healthcare professional said that ‘The person in charge is always fully aware of health issues of the residents’. They said that their instructions for care are not always followed and have to be repeated at subsequent visits. They thought this was probably due to staff shortages. Three care plans were looked at, to make sure that people’s health and personal care needs are being met in the way each person prefers. The plans cover each area of the individual’s care needs. They all contain information to guide staff in how to care for and support each person. The care plans need further improvement, building on the work started by the Deputy Manager, to make sure they fully reflect people’s care and support needs. The plans are straightforward and easy to follow and each area of a person’s needs is detailed on a separate sheet. The risk assessments need more work, to both assess potential or actual risks and to put plans in place showing how risks can be minimised, without compromising people’s choice and independence. People said that staff are very good and understand their needs. They said staff do what people want, in the way people prefer. People said they are happy with the care they receive. The care plans are reviewed regularly and show that, where possible, the individuals and their families are involved in developing and reviewing their plans. One relative confirmed they are always involved in the care planning process, although not all the plans have been signed to confirm that people and/or their relatives have been consulted. The daily records are kept up to date and include information on significant occurrences. There are systems for highlighting information that needs to be passed onto the next group of staff. One healthcare professional said ‘I am satisfied with the care given to my patients’; another told us the home ‘treats clients as individuals (and) promotes independence’. The medicines are kept safe and secure and the Medicines Administration Record (MAR) charts are securely stored. For security, the medicine cabinet was locked during the time between giving each person their medication. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some is kept in the original packaging. The MAR charts, which must show clearly the quantities of medicines received and in stock for each person, were examined. The medicines supplied in the monitored dosage system appeared to be administered and recorded accurately. There were signatures to confirm that The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 13 staff had administered the medicine. During the inspection the member of staff administering medication observed each person taking their medicine and signed the chart immediately afterwards, to confirm this. The records of amounts received, administered and in stock of some medicines that were supplied in their original packaging were accurate. However, a ‘brought forward’ system would make it easier to check all quantities of medicines, to confirm that administration is always accurate. One healthcare professional said that the staff contact the pharmacist immediately there is any change in medication and the home consults the pharmacist if there are any problems.. The pharmacist confirmed that ‘…the senior staff have been trained in medicines management’ and this training is ‘topped up’ by the pharmacist. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. People’s relatives and visiting healthcare professionals confirmed this. Everyone said the staff listen and act on what they say. The Orchards DS0000001167.V369203.R02.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): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities. People are offered a good choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The part-time activities co-ordinator and the staff provide a range of activities for people to take part in, if they wish. One person who lives at the home said that ‘The level of activities has increased over the last few months…’. At present the activities include singing and music, dominoes and other activities that people choose. An external activities organiser comes into the home to do music, exercise and activities sessions. People also enjoy reflexology, aromatherapy and manicures. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 15 Some people like to do some baking with the cook and people said they enjoy sitting outside, when the weather is good enough. The home arranges trips out and plans to expand this in the future. People’s care plans include life histories, which help staff to know people better and plan activities they will enjoy. People said they always or usually like the meals. One person said the home offers ‘Good home cooking and generous…portions’. Another person said that ‘The meals are nicely served…and balanced’. The cook explained how the menus are planned, to include the wishes of the people who live at the home and to meet any special dietary needs. There is a choice of two main courses and two desserts at lunchtime. At teatime there are hot and cold choices and home made cakes. There are always alternatives available if people do not want the choices on the menu. A record is kept of exactly what foods are served each day, as this can vary from the planned menu. People are offered hot and cold drinks throughout the day and trays of cold drinks are kept in the lounges. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 16 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): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people at the home are safe. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. Staff said they know what to do if anyone has concerns. The relatives said the home always or usually responds appropriately to any concerns. People said they know what to do if they have a concern or complaint. One relative said that ‘…any complaints are acted upon’. Newly employed staff are made aware of the home’s ‘whistle blowing’ policies and procedures, to be used if they suspect abuse or see examples of poor practice. All of the care staff have had adult protection training, and further refresher training is planned. All the appropriate policies and procedures are in place to guide staff. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 17 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): 19, 20, 25 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe, comfortable and generally well-maintained environment. EVIDENCE: The home is clean, odour free and generally well maintained and there is an ongoing refurbishment programme. The manager said they are on target with their programme of re-decoration for this year. Since the last inspection a new passenger lift has been installed. This has automatic doors and makes it easier for people to use the lift independently. Fitting the lift meant that some remedial building work had to be carried out as the new lift is narrower than the old one. This work needs to be completed as The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 18 the new skirting boards do not match the existing ones and some cracks have developed in the walls and cornices near the lift shaft on both floors. The areas near the lift need to be re-decorated, as there is bare plaster on the walls. The entrance, hallways and stairways would benefit from being redecorated in order to make the home fresher and more attractive for the people who live there and their visitors. The bedrooms are clean, nicely furnished and well looked after and some rooms have recently been re-decorated. One of the radiators in the dining room did not have a protective cover on it. A cover is needed to make sure people do not hurt themselves if they touch the radiator when it is hot. The room where the washing machine is installed is also the sluice room, where commode bowls are left to soak and mops and buckets are stored. This is a small room with no natural ventilation; an extractor system would make the atmosphere more pleasant. The gardens are safe and well looked after and people enjoy sitting out or walking round them when the weather is good enough. Work to improve the access to them, and create a sensory garden is planned. They are planning to install a ramp leading to the rear entrance to the home. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 19 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): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require to be able to meet people’s needs. EVIDENCE: The staff rotas confirmed our observations that there are enough staff on duty to meet people’s care, social and leisure needs. The home is now at full occupancy and there are three care assistants on the morning shift, two on the afternoon and early evening shift and two waking staff during the night. The staff confirmed that staffing levels are adjusted to meet people’s needs. One person who lives at the home said that sometimes the home is ‘…short staffed’ and one healthcare professional also said that there does not always seem to be enough staff on duty. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 20 register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. Staff have a copy of the terms and conditions of their employment. The staff files are well organised and all the information needed was clear and easily available. Staff confirmed that they have plenty of training opportunities to support them in their roles. Staff said their training was relevant, helped them understand their role and kept them up to date. Training certificates are kept in people’s files and when staff attend a course they feedback information to their colleagues. Six of the care staff have completed a suitable National Vocational Qualification (NVQ) in care at level 2 and one is taking the award. Four care staff have achieved the NVQ level 3 award and three staff are working towards the qualification. All new staff take induction training as well as the mandatory health and safety training courses. This gives them basic training to help them do their job effectively, and provides a basis for taking an NVQ course. Currently all staff take the mandatory health and safety and adult protection training, and have regular refresher training to keep their knowledge and skills up to date. In addition staff training includes infection control, medicines administration, dementia care and the principles of care and person centred planning. Some staff have taken a course in palliative care and the acting manager is planning training on the Mental Capacity Act. One member of staff is a moving and handling training facilitator and this helps make sure all staff are up to date with best practice when assisting people. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 21 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): 31, 33, 35, 36, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally safe and well managed, in the best interests of the people who live there. EVIDENCE: Since the registered manager left in November 2007 the home has been managed by the registered provider and the deputy manager. The deputy manager is now the acting manager and is in the process of applying to us for registration as a suitable person to safely manage the home. The acting manager is currently taking the NVQ level 4 award in care and when this is completed she will take the registered managers’ award. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 22 The records and the staff confirmed that all staff are now having regular one to one supervision meetings with their line manager. This supports staff to plan their personal and professional development and gives them the opportunity to discuss any areas of concern in a confidential setting. People’s personal information is stored in locked cabinets when it is not being used. The home’s policies and procedures are kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. The home’s kitchen has recently had an Environmental Health Officer’s inspection. The kitchen was awarded two stars out of a possible five. Since then the home have carried out work to comply with the requirements, although some work is still to be completed. The laundry is well organised and people’s personal clothing, as well as their bedding and towels, are properly cared for. During the visit we saw some cleaning materials left out; when not being used these should be stored safely. The acting manager dealt with this straight away. The home has a range of quality assurance systems in place, to help determine the quality of service the home offers. These include surveys for the people who live at the home and their relatives, meetings for people and their relatives, staff meetings and regular audit checks. Any involvement the home has in helping people to manage their personal finances is dealt with by the home’s administrator. This is restricted to payment for newspapers; any other expenses are dealt with by sending invoices to the person responsible for paying people’s bills. The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X X 3 3 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 X 3 X 3 3 3 2 The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 24 NO Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Orchards DS0000001167.V369203.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000001167.V369203.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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