CARE HOME ADULTS 18-65
208 Cherry Tree Road 208 Cherry Tree Road Blackpool Lancashire FY4 4PT Lead Inspector
Mrs Jackie Riley Unannounced Inspection 5th January 2006 10:30 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 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 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 208 Cherry Tree Road Address 208 Cherry Tree Road Blackpool Lancashire FY4 4PT 01253 693101 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) Ms Deanna Neal Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: 208, Cherry Tree Road, is close to all local amenities and facilities. A wide range of shops and supermarkets are in walking distance and a bus stop is immediately outside the premises. The premises are in keeping with the local community and domestic in character. Accommodation within the house are single rooms for the two residents, with lounge and dining areas, as well as a garden area which is not overlooked. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory inspection for 2005-06. It was unannounced and undertaken during a weekday period. The inspection examined a number of National Minimum Standards, including medication, support, choice diet and protection. These key issues will be focused upon in the main body of this report. During the inspection the registered person assisted the inspector with the process. Two residents were spoken to generally throughout the inspection process and comments will be included in the report. What the service does well: What has improved since the last inspection? What they could do better:
The home owner must make sure medication storage and administration records are kept up to date to ensure that an accurate record is kept. Plans of care for the service users must be kept up to date to show that they are being cared for. The views of people who use the service should be sought as part of the monitoring process in order to make sure the stated aims and objective of the home are being met. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 6 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. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Residents plans are care should be kept up to date to ensure consistency with the care delivered. EVIDENCE: A plan of care assists the registered provider to help individual residents achieve their maximum potential in their lives. This ensures they can individually live to their full potential and within acceptable boundaries of personal risk, so that they are protected. However the plan must be up to date for all people living in the home, so that it demonstrates the current level of need for people living there. Residents spoken to say they liked the way they live their lives in the home and have choice in all aspects of their daily lives, but were aware of the need for boundaries to protect them from areas of risk to themselves and others. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 17 Residents are encouraged to maintain and develop relationships with family and friends and to develop personal relationships, which meets individual needs and retains their personal rights. Meals are balanced nutritional and are chosen by people living at the home. EVIDENCE: There is an open policy on visiting at the home and beyond, so that residents know they can receive visitors and develop personal relationships as and when they choose. One resident said, “My family can come whenever they want, and we can see them in our own rooms”. Residents rights are upheld in that individual choice and how they choose to live their lives is accepted by the registered provider, so that the way care is delivered is set by individual choice, based on risk assessment. Meals are prepared on the premises, with fresh produce used at all times. Residents spoken to said they can have what they like, and enjoy choosing their meals. There are no set routines for meals, with residents having their
208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 11 own pattern of eating times set for themselves, so that flexibility is there at all times, however in general there are times when they all dine together. The registered provider is aware of the need for a good balanced diet and this is incorporated into the meal planning arrangements. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents health care is taken seriously and needs are closely monitored ensuring health issues are met. Support is provided in a sensitive and noninvasive manner. Management of medication must demonstrate suitable recording and storage for the safety and protection of people living at the home. EVIDENCE: Records examined indicated the registered provider is aware of the need of ensuring personal care and support is provided in a sensitive manner, at all times. The registered provider commented they always respect resident’s dignity and privacy. One resident said, “I like my own privacy”. Records of the residents were examined and they contained the information required in relation to health care and all needs are being met. The recording and storage of medication must be improved upon, so that people living at the home are protected at all times, and that there is evidence of drugs administered. There must be evidence of a locked facility appropriate to store medication in the home, so that there is no risk to people living at the home.
208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Arrangements for complaints are handled well and taken seriously ensuring people feel listened to. EVIDENCE: The home has a complaints procedure, which has been made available to residents living at the home. One resident spoken to said “I tell them about things I’m not happy with, if I need to”. There have been no complaints since the last inspection the home has a procedure in place for dealing with allegations of abuse. The registered has a knowledge of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic and a comfortable environment in which people live. EVIDENCE: The home is furnished in a domestic manner and resident’s rooms and living areas are clean and hygienic, so that people living there are comfortable in the homes environment. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected. EVIDENCE: 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Resident’s views are acted upon and listened to so that changes are made accordingly for their best interests. EVIDENCE: As this is a small home with two residents living there, there is no formal approach to monitoring and review, however there is evidence the residents views are listened to and acted upon so that the home is run in the best interests of people living there. One resident said “I tell them if something needs changing or I don’t like it”. Recording users of the service views would be useful in order to know if the homes stated aims and objectives are being met and changes could be made if necessary. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 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 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 3 X X X X 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 18 Yes 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. 1. Standard YA43 Regulation 25©(e) Requirement Timescale for action 28/02/06 2 3 YA6 YA20 15 13(2) The registered provider must produce a business and financial plan and ensure suitable insurance cover is in place commensurate with the level and extent of activities undertaken. (Previous timescale of 15/09/05 not met) The registered provider must 28/02/06 keep individual written service user plans up to date. The registered provider must 28/02/06 ensure the safekeeping, recording and storage of medication at all times. 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 YA39 Good Practice Recommendations It is recommended the views of people who use the service are sought in order to make sure the stated aims and objectives of the home are being met. 208 Cherry Tree Road DS0000009973.V275744.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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