Inspection on 27/10/06 for Cherry Garden Nursing Home

This inspection was carried out on 27th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cherry Garden Nursing Home 22/10/08

Cherry Garden Nursing Home 01/12/05

Cherry Garden Nursing Home 09/06/05

Cherry Garden Nursing Home 08/03/05

Cherry Garden Nursing Home 09/11/04

Cherry Garden Nursing Home 11/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Cherry Garden Nursing Home. Breadcroft Lane Littlewick Green Maidenhead Berkshire SL6 3QF Lead Inspector Amanda Longman Unannounced Inspection 27th October 2006 10:30 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 Garden Nursing Home. DS0000010980.V305731.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 Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Garden Nursing Home. Address Breadcroft Lane Littlewick Green Maidenhead Berkshire SL6 3QF 01628 825033 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) Amberbrook Limited Mrs Gillian May Elston Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Cherry Gardens is a care home with nursing registered for 36 older people. The home is not registered to admit people whose primary diagnosis is dementia. The home is a large property in a rural location. Access to the property is best achieved in a motor vehicle. The accommodation is on two floors. All of the communal areas are downstairs; these are spacious and overlook the gardens of the home. Eight of the rooms are used for double occupancy. This home was registered prior to 31 March 2002, therefore there are rooms in the home that are smaller than the present standards. There are seven single rooms under 10 square metres. Charges in the home vary between £550 and £720. Extra charges are in place for hairdressing (from £9.50), chiropody (from £16.50) and television rental (from £15.00). Telephones can be arranged directly with the supplier and daily newspapers can be ordered. The home has an equal opportunities policy in place. It welcomes people from all religious and cultural backgrounds and currently is regularly visited by ministers from four different religious organisations. It has an appropriate policy on racial harassment which was reviewed in April 2006. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that the Commission has received about the service since the last inspection. The inspection included a visit to the service on 27 October 2006 between 10.30am and 4.15pm when the inspector observed care practices, examined care records and staff records and spoke with staff, service users and relatives. A second site visit was made on 30 October 2006 between 10.45am and 1.45pm to examine policies and conduct more detailed interviews with service users. In advance of the site visit questionnaires were received from ten service users. What the service does well: What has improved since the last inspection? Both requirements made at the previous inspection have been met - ensuring that all staff have clearance from The Criminal Records Bureau before commencing work and that all the recommendations from the previous occupational therapist’s report have been implemented. Care plans have been reviewed and placed in a more comprehensive format in the last 12 months and a new induction procedure and foundation training programme started on 1st September 2006. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 6 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. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 7 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 Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 3 Quality in this outcome area is good. Service users have the information they need to make an informed choice about where to live and the home is in the process of ensuring that all service users have contracts. All service users have their needs fully assessed. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: The Statement of Purpose and Service User Guide are appropriate. They were reviewed in September 2006 and contain all the required information. There is also a residents’ charter in place, which covers the areas of choice, dignity, fulfilment, privacy, independence and citizen’s rights. All service users who returned a questionnaire said that they had sufficient information to make a decision about the home prior to admission, and this was confirmed by those service users spoken with, although not all had been able to visit Cherry Garden before moving in. The registered manager stated that they would like more service users to have pre admission visits to assess their needs within the home and plans to work on persuading care managers of the value of this. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 9 Pre-inspection information received did not confirm that all service users have received contracts. Seven out of ten service users who replied to the questionnaire had received a contract, two others did not receive one but said this was because they were funded by social services. The manager informed the inspector that it had come to light, when filling in the pre-inspection quality audit, that service users funded by social services were not routinely issued with contracts. This is now being rectified and all service users have been issued with contracts. The manager is waiting for the signed copies to be returned. An appropriate assessment procedure is in place which was reviewed in April 2006. All service users receive an assessment and assurance that their needs can be met prior to admission. Staff attend these assessments so that they are aware from the outset of assessed needs. All service user files examined contained a full assessment of needs. The manager commented that they would like all service users to visit the home prior to admission and, for those who so wished, to have an opportunity to return to their own home before admission to collect and choose possessions to bring with them. The home does not offer intermediate care. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. Service users have their care needs documented and appropriately met and have their privacy and dignity respected. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: Care plans identify health, personal and social care needs. They have been revised into a more comprehensive format in the last 12 months and all the records examined contained detailed and up to date information in sections addressing all physical needs, as well as working/playing, communicating and sexuality. They also contain a section on needs and wishes around dying but these were blank on the records examined. The manager explained that staff found this difficult to discuss with service users. Policies regarding death and dying are in place but this issue needs to be addressed to ensure any personal, religious and cultural needs or wishes are adhered to. The manager would also like social care plans in more depth and the inspector discussed with the manager improvements, which could be made in terms of identifying social and personal goals with service users. The care plans are reviewed monthly. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 11 Care plans contained detailed health information. All ten questionnaire respondents said they usually or always (70 ) received the care and support they needed and usually or always (80 ) received appropriate medical support. Comments were made about staff always having time for service users and having an excellent doctor on call. The profile of the home is one of high dependency, with nearly all service users requiring help with bathing, dressing and going to the toilet, most being incontinent and eight having dementia. Those service users with dementia do not have it as a primary diagnosis. Policies and procedures are in place to deal with the healthcare needs of service users. Continence promotion and pressure relief policies were reviewed in April 2006. Three service users have had grade 2 pressure ulcers in the last 12 months but none were acquired in the home and all are improving. The GP is aware of all cases and monitors them. They are now photographed to monitor changes. The manager is aware of diabetic service users’ rights to access free chiropody and this had been offered but they have chosen to use the home’s visiting chiropodist. Medication procedures were reviewed in April 2006. No service users currently self-administer medication. Medication records were clear and up to date. Instances of medication being refused are noted and referred to the GP. Medication is securely stored. Keys are only held by the manager or her deputy and the RGN in charge of the shift. All medication held in the home is on personal prescription, no stock items are held. The home’s policy regarding privacy and dignity was reviewed in June 2006. All service users who answered the questionnaire said that staff usually or always listen and act upon what the service user says. From both the questionnaires and discussions with service users and relatives the inspector was aware of many comments about caring and helpful staff and about service users being happy there. All service users who answered the questionnaire said staff were available for them always (eight out of ten) or usually (two out of ten). Service users do not have an allocated keyworker but the home is managed in three groupings with the same staff being allocated to the same service user group to ensure continuity of care. Service users are offered keys to their rooms, but none currently want them – this was documented on the files examined. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Service users’ lifestyles experienced in the home match their expectation and meet their social, cultural, religious and recreational needs, including contact with family, friends and the local community. They exercise choice and control over their own lives and enjoy meals and mealtimes. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: The program of activities showed regular indoor activities including music and movement, a gentleman who comes to play the electronic organ, bingo, quizzes, crosswords and movies. An activity organiser works two and a half days per week and there have been 11 outings since May including picnics, tea dances, a trip to a museum and a trip to the seaside. All service user files contained a personal history and up to date records are maintained regarding each service user’s involvement/enjoyment of activities. The home has good links with the local stroke club and hires a mini bus for outings. The manager feels the activities have improved over the last 12 months and plans to continue varying the activity programme and try to integrate more with the village life and community. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 13 Of those service users who replied to the questionnaire, 80 per cent said suitable activities were always available and ten per cent said usually. Those service users spoken with enjoyed the activities on offer. One relative commented it would be nice to have more weekend activities, which families could join in with. During the site visit it was noted that staff were very welcoming of visitors and made space and included them in activities. Religious diversity is catered for, both Church of England and Catholic ministers come weekly to the home and Baptist and Methodist ministers also come regularly. Other religious ministers can be invited by request. The manager is confident all needs are currently met and service users spoken with confirmed this. The inspector spoke with one service user for whom English is not their first language, who felt their religious and cultural needs were met. The home welcomes visitors anytime up till 10.00pm (later if a service user is unwell). The manager would like to have a visitors room to facilitate overnight visits. Minutes for the last service user meeting held on August, attended by service users and relatives, showed that the discussion included the protection of vulnerable adults and confidentiality. The meetings are held every three to four months. Service users’ wishes are accommodated as far as possible with regard to getting up and going to bed. Of the six service users case tracked, five were spoken with in detail. Four confirmed that the home offered choice with, for example, what time they got up and went to bed and felt they did have choice and control over their own lives. One felt there was not much choice about getting up or going to bed but that you could choose other things, like when to have a bath for instance. The manager explained that the home has introduced a twilight shift to provide extra cover in the evenings to improve choice about going to bed. All service users and relatives spoken with confirmed that there was choice over which activities to join in. All said the home was a nice home with a good atmosphere and that there was often dancing and singing. Staff spoken with confirmed that the home has a good atmosphere, choice is encouraged and that the manager expects very high standards. All service users are offered a key for their rooms and this was documented on the files examined. The home has a varied and nutritious menu. The cook was spoken with. She demonstrated a high level of commitment to providing good food and understanding the dietary needs of the service users. She will talk to service users and try to accommodate their preferences and any cultural requirements. The cook attends mandatory and other training courses and demonstrated a high level of commitment and knowledge, for example the role of protein in wound healing. She is currently completing an NVQ qualification. Service users and staff view the cook very much as part of the team. Of those service users who returned questionnaires 80 said the meals were always or usually good. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 14 Service users and relatives spoken with at lunchtime confirmed that the food was usually good and staff were polite and kind. Care at lunchtime was observed. Staff were appropriately assisting, feeding, and encouraging service users. Alternatives were provided for those that wished. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Service users can be confident that their complaints are taken seriously and they are protected from abuse. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: Policies relating to the protection of vulnerable adults, whistle blowing, concerns and complaints procedures and racial harassment were all reviewed in April 2006. However, the wording in the complaints procedure reads as though CSCI is an appeal body. This was discussed this with the manager who will look at rewording it. No information concerning complaints made to the service have been received by the Commission from service users or their representatives since the last inspection. The home states it has received seven complaints in the last 12 months, one of which was upheld and that all were resolved within 28 days. The records showed that all complaints this year were appropriately dealt with. There have been no issues relating to the protection of vulnerable adults since the last inspection. Staff spoken with confirmed that they are proactive in informing the nurse in charge of complaints and that all are taken seriously and dealt with within agreed timescales. The manager confirmed that she has encouraged proactive documenting of complaints and concerns but would like to improve this further to encourage documentation of minor complaints as a way of improving service user satisfaction. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 16 All ten service users who answered the questionnaire said they knew how to make a complaint. This was confirmed by service users and relatives spoken with at the site visit who were all clear about who to speak to if they wished to make a complaint. The protection of vulnerable adults policy is up to date, appropriate and in line with the local authority practice. Training relating to the protection of vulnerable adults is also up to date and appropriate and in line with the local authority guidelines. Training is provided both in-house and through external courses and reminded in the monthly staff newsletter. Staff spoken with had received training in the protection of vulnerable adults and all demonstrated an appropriate understanding of issues relating to the protection of vulnerable adults and whistle blowing. Cherry Garden Nursing Home. DS0000010980.V305731.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in a safe and well maintained environment, which is clean, pleasant and hygienic. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: All the recommendations from the previous occupational therapist’s report were seen to have been implemented, including the addition of handrails along corridors and ramps in necessary places. All electrical and other safety equipment is serviced in line with the manufacturers’ recommendations. The small rooms in the home, occupied by service users who need assistance, have all the necessary equipment to assist with safe handling. A maintenance person is employed who has a regular job sheet of any areas for attention. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 18 A tour of the home, including several service users’ rooms, revealed it to be clean, pleasant and hygienic. Two domestics have now been recruited as part of the team and they keep the home clean and odour free. This is supported by service user feedback. All ten service users who answered the questionnaire said the home was always (90 ) or usually (10 ) fresh and clean. A cleaning schedule is in place and all mops are washed daily at 60 degrees. Cherry Garden Nursing Home. DS0000010980.V305731.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Staff in the home are trained, skilled and present in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: The staff rota for the day was reviewed, care assistants and nurses were in place as per the rota. The rota includes the addition of a twilight worker to ensure that more help is available in the evenings. Staff absences are covered by staff from within the group to help ensure continuity of care. Evidence from the manager confirmed that no agency or temporary staff have been used in the last 12 months. Staff are offered NVQ training, currently through Wokingham and Bracknell College. 75 of care staff have NVQ Level 2 or above. Both the manager and the deputy manager are currently undertaking the NVQ assessors course. The recruitment policy was reviewed in April 2006 and a previous requirement to ensure that all staff have a CRB clearance before commencing work has now been met. The manager explained that the more rigorous recruitment procedures included, for example, authentication references and evidence of this was seen on the staff records. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 20 Induction training and staff development programmes are in place, as is a mentoring programme. All mentors have received supervisory training. The new induction procedure/foundation programme started on 1st September 2006 and is overseen by the deputy manager. A Skills to Care training needs analysis has recently been undertaken. Training records were seen. Training is offered in topics other than mandatory ones and all staff spoken with confirmed that they had received all mandatory training and opportunities for other training, for example the cook has been on various courses which has improved both the relevance and the quality of the catering. Service users and relatives spoken with confirmed that they thought staff were appropriately trained. Cherry Garden Nursing Home. DS0000010980.V305731.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is good. The management and administration of the home is based on openness and respect. Quality assurance systems are in place and record keeping is accurate and up to date. Service users’ finances are protected and the health and safety of service users is promoted and protected. This judgement has been made using available evidence including a site visit to the service. EVIDENCE: The manager is qualified and registered with the Commission. She has reviewed policies and procedures and undergone development training. She has been in post for 12 years and is currently undertaking a master’s degree in The Care of Older People. She is highly thought of by service users, relatives and staff. The manager’s open door policy was witnessed. During the course of the site visit the manager was observed dealing with service users and relatives in person and over the telephone. Her manner is continually polite, supportive and helpful. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 22 She currently manages two homes in the group and her time is shared between them. Although some service users are not happy about this (two comments were received in the questionnaires from service users saying they miss having the matron full time), it does not appear to jeopardise the care of service users. The arrangement was made with the agreement of CSCI as a temporary arrangement and is due to be reviewed. The manager has attended study days on quality assurance and now plans to improve the home’s quality audit plan. Quality is monitored through canvassing service user views and one aspect of the home is audited by the manager each month, for example medication, service plans, policies and procedures, accounts. The manager also wants to encourage better attendance at service user and relatives’ meetings. The home does not currently produce an annual quality assurance report to measure performance against the home’s stated aims and objectives, which could be used to generate an annual development plan. This was discussed with the manager who agreed to take this forward. A full set of policies and procedures are in place. Record keeping within the home was accurate and up to date. Personal information is stored on paper files rather than on computer systems. The home is therefore not currently registered under the Data Protection Act. Should computer systems start to be used for the storage or processing of personal information, the registered manager will need to ensure that the home does register under the Data Protection Act. Service users’ personal funds are kept securely locked in the office. Records were up to date and are audited by the group manager. Health and Safety policies including food safety, fire safety, infection control, first aid, accident policy, the disposal of clinical waste and moving and handling are all appropriate and up to date. COSHH assessments were in place and the policy relating to them was reviewed in April 2006. The COSHH cupboard was seen to be secure. The COSHH sheets are currently stored in the office and include old sheets relating to products no longer used. The inspector discussed with the manager the need to remove old sheets, the possibility of minimising the number of products used and of having ease of access to COSHH sheets perhaps by having them displayed in laminated forms. The manager agreed to look into this. The health and safety policy is issued to staff on the first day of induction. Health and safety training is undertaken through distance learning with a tutor visiting once a month and an exam is taken at the end. Staff spoken with were knowledgeable about appropriate procedures. Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 23 A fire evacuation plan is in place which contains individual risk assessments for service users. Fire safety training is being held for all staff this year. The first group was in March and the remainder on 17 November. The accident book was up to date and crosschecked to the daily records for service users. All service users’ records contained up to date risk assessments and management plans, including manual handling. Staff spoken with said they had appropriate equipment and service users said staff helped them using appropriate techniques and equipment. Cherry Garden Nursing Home. DS0000010980.V305731.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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X 3 3 Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 Refer to Standard OP7 Good Practice Recommendations To ensure service users’ needs are fully met, the registered manager should give consideration to recording any personal goals service users have, as part of their personal plan. To ensure any personal, religious and cultural needs or wishes are adhered to at the time of death, the registered manager should give consideration as to how to enable staff to discuss the relevant policies with service users and record their wishes on their care plans. The registered manager should consider revising the complaints procedure to clarify that The Commission for Social Care Inspection does not function as an appeal body. 2 OP7 OP11 3 OP16 Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 26 4 OP33 The home does not currently produce an annual quality assurance report to measure performance against the home’s stated aims and objectives. The registered manager should give consideration to producing one which could be used to generate an annual development plan. To ensure minimum risk from dangerous substances the registered manager should consider removing old sheets relating to The Control of Substances Hazardous to Health (COSHH sheets) from the current file relating to cleaning and other products used within the home. 5 OP38 Cherry Garden Nursing Home. DS0000010980.V305731.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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 Garden Nursing Home. DS0000010980.V305731.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. 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