Inspection on 11/04/08 for Cherry Acre

This inspection was carried out on 11th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cherry Acre 27/02/09

Cherry Acre 23/10/07

Cherry Acre 27/04/07

Cherry Acre 06/10/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cherry Acre 21 Berengrave Lane Rainham Gillingham Kent ME8 7LS Lead Inspector Sue McGrath Unannounced Inspection 11th April 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Acre Address 21 Berengrave Lane Rainham Gillingham Kent ME8 7LS 01634 388876 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) cherryacre5@aol.com Uday Kumar Kiranjit Juttla-Kumar Uday Kumar Care Home 17 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (16) Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2007 Brief Description of the Service: Cherry Acre Residential Home provides personal care and accommodation for up to 17 older people and is owned and managed by Mr Uday Kumar. The home does not offer nursing or intermediate care. The home occupies detached premises and is located in a residential area, close to local shops and on a bus route. The premises are large with ample parking and established mature gardens to the front and to the rear of the property, which are easily accessible. Residents’ accommodation is arranged over two floors. There is no passenger shaft or stair lift to the second floor. A call bell is installed within each of the 17 single bedrooms to alert staff; all bedrooms have television aerial points. Telephone points can be installed if required at the individual’s cost. No bedrooms have en-suite facilities. All bedrooms include a wash hand basin. The home employs care staff working a roster, which gives 24-hour cover. Ancillary staff for catering and domestic duties are also employed. Current fees range from £323 to £500 per week according to assessed personal need. Please contact the manager for further information. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and that the outcomes are promoting the best interests of the people living in the home. The IBL process for a Key inspection involves a pre-inspection assessment of service information obtained from a variety of sources including an annual selfassessment and surveys. It is now a legal requirement for services to complete and return an Annual Quality Assurance Assessment (AQAA). This assessment is aimed at looking at how services are performing and achieving outcomes for people. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable The Commission for Social Care Inspection (CSCI) to be able to make an informed decision about each outcome area. Further information can be found on the CSCI website with regards to the IBL process including information on KLORA’s and AQAA’s. The actual site visit to the service was carried out over one day by one inspector, who was in the home from approximately 09.00 until 18.00. The main focus of the visit was to review any improvements made since the last visit and the well-being of the service users. Time was spent touring the building, talking to people living in the home, talking to staff and reviewing a selection of assessments, service user plans, medication records, menus, staff files and other relevant documents. Prior to the site visit the AQAA had been returned and surveys had been sent out to service users, families and professionals to gain further feedback as to their opinion of the service. A number of surveys had been returned. At all times the manager and staff were helpful and demonstrated a pro-active approach to ensuring that service users were being supported to the best of their abilities and resources. This report contains evidence and judgements made from observation, conversation and records. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 6 Statements made during the inspection included: ‘I like it at this home- and am very happy’ ‘The girls look after me very well and listen to me which is nice’ ‘ I like watching and feeding the birds and squirrels’. ‘The food is very good and we always get a choice’ What the service does well: What has improved since the last inspection? New carpets in nearly all areas of the home have improved the appearance and freshness of the home. The kitchen has had new flooring and a new fridge freezer. The worktop around the sink has been replaced. The laundry room has new flooring, new sinks and some new worktops. A new ramp to the front of the building has improved disabled access for residents. More handrails have been added to the stair well along with safety treads on all stairs. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 7 New radiator covers in most areas protect residents from the possibility of burns and thermostatic mixer valves also reduce the risk of scalding. New toilets pans enable domestic staff to ensure they are clean and hygienic. More staff are completing NVQ in care and the majority of staff have received training in safeguarding adults and fire awareness. 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. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are provided with the information they need to make an informed choice about moving into the home. Residents’ benefit from an assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. EVIDENCE: Evidence of the updated statement of purpose and service users guide were seen in each residents bedroom. This document now reflects what the home offers to the residents and complies with Schedule 1 of the Care Standards Act Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 10 2001. It was also seen that the statement of purpose could be provided in an audio format for residents with a sensory impairment. Evidence was seen of resident’s contract/statement of terms and conditions on resident’s files. These were discussed with the registered manager and contained information on what was included in the fees and what was extra, such as hairdressing and chiropody. Further evidence was seen that the owner assesses all prospective residents and a formal assessment is completed. The registered manager also endeavours to obtain assessments from any Social Services Care Manager. It was confirmed by a new resident that personal information was sought by the home prior to his admission. The home’s own pre admission documentation has been be improved upon and an admission checklist was seen in a new residents file. The owner confirmed there were opportunities for residents or their representatives to visit the home before admission to assess suitability and residents are encouraged to visit and stay for lunch prior to admission. The owner confirmed there was also a four-week trial stay; this could be flexible according to need. Many of the residents were spoken with and all confirmed they felt well cared for. One relative said that when her aunt was poorly the staff cared for her very well and another relative confirmed she felt comfortable to leave her Mum in the care of the staff. Staff training has improved and continues to be ongoing. Several staff are about to start training in dementia care. This home does not provide intermediate care. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from improved care plans, however their safety may be put at risk, as the care plans do not contain sufficient risk assessments that address how to fully support service users in meeting their needs. Personal health care needs are well met, staff respect privacy and dignity and are sensitive to changing needs. EVIDENCE: A considerable amount of work has been undertaken with regards to the contents of each individual care plan. The actual plan contain basic information regarding personal needs but, as explained to the owner, could be further improved if more detailed information was recorded. There remains a lack of robust risk assessments and it was evident that senior staff would benefit from some training in risk assessments and of their importance to good care Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 12 planning. Each individual risk that is identified must have a corresponding action to reduce the risk. Risk assessments covered a range of issues without giving clear guidance to staff on how to reduce the risks. One risk assessment for a resident covered diabetic care, catheter care and walking. The only outcome was ‘ be careful as known to have falls in the past’. Evidence was seen and was confirmed by some of the residents that they are involved with the plans being drawn up and in the regular reviews. Daily notes were robust and detailed. Evidence was seen and crossed referenced of good documentation following a fall by a resident. All medical intervention notes were seen and evidence proved the accident was followed up and well recorded. The section in the care plan that reflected health professional’s input was also well recorded. Again risk assessments for specific medical conditions which gives clear guidance to staff could be improved upon. These include diabetes and catheter care foe example. Nutritional assessments are now being undertaken on admission and subsequently on a periodic basis. More attention could be given to the social and spiritual needs of the residents. Religious needs for the residents who require it are met with regular visits from the local church. The new manager would benefit from further training in care planning. The administration of medication was assessed and it was noted that some staff have started long distance ‘Assett course’ in ‘The Safe Administration of Medication’ as discussed at the last inspection. One concern is that the new manager, who has not completed the course herself, is assessing the staffs competencies. It is recognised that she has recently started the above course but as with other staff, is in the early stages. These assessment should be carried out by someone who can evidence they are competent to assess others in this field. The owner stated he completes regular audits of the medication but was unable to find the written evidence, however no errors were found during the inspection. There remains no policy or procedure for residents who may elect to selfadminister medicines, neither is there a risk assessment to establish an individuals capacity to do so. Currently all of the residents have any prescribed medication administered by the home. The homes medication is stored in a lockable medicines trolley, in the dining room, which contained medication currently being administered. They used a monitored dosage system (MDS) provided by a local pharmacy. Extra stock was safely stored. The security of keys to medication storage areas meets best practice and was retained by the senior carer and handed over formally between shifts. The owner is currently in the process of having locked drawers fitted to all of the bedrooms. This is ongoing work. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 13 Residents spoken with confirmed that staff were respectful and polite and very caring. Staff were seen to be polite and attentive and had a good understanding of the individual residents needs. Staff were seen to knock before entering bedrooms and to use preferred names when talking to residents. The atmosphere was relaxed and comfortable. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents social and recreational interests and needs are well provided for with a wide range of activities organised. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: There was evidence that the home now has an organised activity programme that is mainly adhered to. Activities in the home were said to include bingo, card games, tabletop games, weekly sing-along, mobile library services, monthly motivation classes and movie matinees. Music sessions were also popular with the residents. Several resident confirmed they recently enjoyed an outing to a local fish and chip shop for lunch and most said they were looking forward to further trips out. It is strongly recommended that they be consulted on where they would Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 15 like to go and that appropriate risk assessments are carried out prior to any visits to ensure their well-being and safety. Several of the visiting relatives confirmed they were always made welcome and could visit at any time. They also confirmed the home kept in touch with them over any changes in the conditions of their relatives and that they felt involved with their care. Residents commented that they felt able to choose how to spend their time during the day and staff respected their choices and preferences. It was evident during the inspection that some residents preferred to remain in their own rooms, this was reflected in the care plans and staff were fully aware of who preferred to be where. Generally residents daily life had improved recently and they felt free to make choices about their daily living arrangements without having to ‘ ask for permission’. Regular church services are arranged in the home for residents if they wish to attend. The Salvation Army regularly visits at Christmas and traditional days such as St George’s day are celebrated. Evidence was seen and residents confirmed that residents meetings were now happening on a fairly regular basis and they felt they could always approach the manager or owner if they wanted to raise any issues. Most recent meetings were conducted on 24/12/07 and 29/02/08 Residents made very positive comments regarding the food and all said a choice was given. The kitchen had a new sink and worktop and a new fridge/ freezer. All records were adequately maintained. Cherry Acre DS0000066219.V361248.R01.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The home had a complaints policy in place, which now gives details of timescales and was included in the statement of purpose. Residents spoken with were confident that the owner would address any issues raised quickly and visiting families agreed. The home had recorded one minor complaint and this had been handled appropriately. Staff had also complained about a visiting professional and the owner was addressing this in a timely manner. This indicated that staff are willing to speak up on behalf of the residents when they felt they could not. This reflects highly on the staff group. The commission had not received any complaints and there are no Safeguarding Adults Alerts currently raised on the home. The majority of care staff have now received training in safeguarding vulnerable adults, as required from the last inspection. The only remaining staff member that has not been trained is to complete the course in the very near future. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 17 One concern was the fact that not all staff had undertaken a POVA first check or held current CRB (Criminal Record Bureau) check. This was discussed with the manager and an immediate requirement was made. The owner confirmed in writing within seven days that these had been applied for retrospectively. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. EVIDENCE: The owner has invested heavily in the fabric of the building and this has greatly improved the internal environment. New carpets had been fitted to the lounges, hallways with safety treads and all bedrooms. The dining room had newly fitted wooden floors. There was also new flooring in the kitchen, laundry and bathrooms. The kitchen had a new sink and partial worktop and a new fridge/freezer. The laundry room had been improved with new sinks and worktops fitted. New toilet pans had also been fitted throughout. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 19 Radiator covers had been fitted in the majority of areas and this will be ongoing until all are covered. The upstairs windows now have restraints fitted as required from the last inspection. Extra handrails had been fitted to the stairs. The manager confirmed that new dining room chairs had been ordered and some improved furniture had been purchased for the lounge. During the inspection an environmental assessment was ordered from a Health and Safety advisor. The issue over the installation of the lift was discussed and the owner confirmed permission had been granted and that the expected work was due to start in the spring. This will mean part of the roof has to be lifted, so the manager is advised to ensure adequate risk assessments are in place prior to starting the work. The owner stated he was waiting for the better weather before starting with the planned work. All portable electric appliances had been tested and a certificate issued. Lifting equipment in the home had been serviced. The home’s water system had been tested for Legionnela and found to be clear. A digital thermometer had been provided to ensure residents bath water was prepared at the correct temperature for safe bathing. Evidence was seen that water temperatures are regularly monitored and TMV’s (Thermostatic Mixer Valves) are in the majority of rooms. A general tour of the building confirmed that the home was generally cleaner than at the previous inspections, but some beds had been poorly made and the bedding was stained and very thin. This needs to be addressed both by looking at working practises and the possible purchase of new bedding. Some of the commodes were dirty and the home must reviewed the procedure for the disposal and cleaning of commodes and related body fluids. The home does not have a sluice and consideration should be given to the purchase of such equipment to ensure sound infection control practises. The owner discussed the issue of retaining domestic staff as the current cleaner had recently left abruptly. This remains an ongoing problem for the home but one that needs to be addressed urgently and comprehensively. A cleaning schedule was in place but not monitored by senior management. The exterior windows are in urgent need of repainting and this needs to be included in any financial planning for the home. All of the resident and families spoken with commented on how much work had been completed recently and all said they liked the new carpets. Some said the home was a bit cleaner. No odours were detected during the inspection. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by staff who have a good understanding of their needs and are committed to training. Residents safety may be compromised by the home’s recruitment procedures not being adhered to. EVIDENCE: There have been some changes in the care staff since the last inspection and some new and enthusiastic staff had joined the staff group. Some have come with a wealth of experience and qualification. The home normally has two members of staff on duty at all times and this mainly meets the needs of the residents currently in the home. Some residents still say the ‘the girls are always very busy’, but no major complaints were made. Visitors and residents made some very positive remarks about how pleasant and caring the staff were towards them. One major concern was the lack of a Pova first check and a current CRB check for two staff at the home. This was discussed with the owner and an immediate requirement was made. The owner discussed how he had made the new manager aware of what was needed in the recruitment procedure but had not monitored the progress, which has resulted in this situation. It remains the Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 21 registered managers responsibility to ensure all personnel checks are appropriately carried out. The required checks were applied for within the following seven days. The home has an equality and diversity checklist for the recruitment programme but the manager confirmed this was not yet in use. Staff training has been ongoing with several courses completed i.e. fire protection and safeguarding vulnerable adults. This is an ongoing process and will need to be maintained. Several staff are currently undertaking NVQ (National Vocational Qualifications) and medication training. According to the information given in the AQAA of the fifteen members of staff, three have completed an NVQ level two or above and eight are currently undertaking their award. When they have completed their award the home will have in excess of the 50 required. The cook is currently undertaking an NVQ in catering and nutrition. Some staff are in the process of applying for in depth dementia training via a distance learning programme. Some mandatory training such as moving and handling and first aid need to be completed by all staff. The home does have a basic induction course in place and the owner confirmed he has a meeting planned with Skills for Care to improve the level of induction at the home and induct to the Common Induction Standards. Some evidence was seen that the new manager was assessing staff as competent in care practises during induction but, as the owner confirmed, the new manager is new to care work. The owner/registered manager should question the appropriateness of this. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home where the owner/registered manager is enthusiastic and experienced with the care of older people and has a clear vision for the home. Residents do not benefit from having staff that receive regular and structured supervision. EVIDENCE: The owner has made some major improvement to the environment of the home, which is very positive. Certain areas of the management remain of Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 23 concern. Mr Kumar confirmed the recent recruitment of a new manager has relieved some of the pressures of the role, however too much reliance has been put on this member of staff, who the owner confirmed, has no management experience or experience in the care field. If the new manager is to gain these skills she must undertake extensive training. The owner is strongly advised to continue to monitor closely the concerns raised in this report over the management of the home. Staff and residents confirm that the owner and new manager are approachable and eager to please. Staff supervision one area of concern. It could not be evidenced that regular and appropriate supervision is being undertaken. The records show and staff confirmed that it is not undertaken on a regular basis. Staff who give supervision must be fully trained in what is the expected and should include all aspects of care practise, philosophy of care in the home and career development needs, as stated in the guidance in the National Minimum Standards (NMS). The NMS state that staff receive formal supervision at least six times a year. Records must be clearly maintained and available in staff files for inspection. The quality assurance process is still ongoing. Residents meetings are now happening regularly (24/12/07 and 29/02/08) and records are kept. Residents also confirmed these meetings are productive. Questionnaires were currently being sent out to relatives and service users views had been sought by the home. Mr Kumar stated that there was very positive feed back from residents and that he was working with the Kent Care Home Association on the framework for a quality development plan. This work was ongoing and not yet complete. Comment cards received by the commission from relatives and residents were mainly positive. Regular fire drills are now happening and are recorded and all staff have received practical training in fire safety. The home has a current Fire Safety risk assessment completed by a specialist consultant. Regular safety checks are undertaken, including the fire system; emergency lighting, water temperatures and all call points. Hoists are regular serviced and PAT (Portable Appliance Testing) is up to date. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 1 3 3 3 X 2 3 3 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X 1 X 3 Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation 18 1(a) Requirement Staff are to receive training in all aspects of care and safe practice and this is to include: Fire Training First Aid Moving and Handling Care Planning Health & Safety & COSHH Risk assessment Infection Control Food hygiene. With refresher training and assessment of competency within good practice guidelines This requirement has not been met from the previous inspection. An improvement plan detailing how the service will address this must be forwarded to the Commission within the timescale indicated There is evidence that this is being addressed but there are still some gaps for core training. Training Certificates must all be available as evidence of compliance on staff files. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 26 Timescale for action 31/07/08 This has been carried over from two previous reports RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP7 OP30 OP30 OP30 OP26 OP24 OP36 Good Practice Recommendations It is recommended that care plan continue to be improved by having more robust risk assessments that give clear guidance to staff on how they can reduce risks. It is recommended that staff who carry out risk assessments must be fully trained. It is recommended that staff who deliver supervision are fully trained. It is recommended that the staff induction programme be improved. It is recommended that commodes are kept fully clean as dirty commodes increase the chances of cross infection. It is recommended that senior staff monitor the quality of bed making and the condition of the sheets. It is recommended that the registered person ensure that staff supervision follows the guidance given in the NMS. Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cherry Acre DS0000066219.V361248.R01.S.doc Version 5.2 Page 28 - 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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