Inspection on 13/07/07 for Cherry Lodge

This inspection was carried out on 13th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherry Lodge 20/06/08

Cherry Lodge 25/10/06

Cherry Lodge 16/05/06

Cherry Lodge 11/10/05

Cherry Lodge 21/07/05

Cherry Lodge 04/11/04

Cherry Lodge 13/05/04

Cherry Lodge 08/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Cherry Lodge 14 Lynton Road New Malden Surrey KT3 5EE Lead Inspector Adrian Gordon Key Unannounced Inspection 13th July 2007 10:00a Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry Lodge DS0000013379.V345969.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 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. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Lodge Address 14 Lynton Road New Malden Surrey KT3 5EE 020 8296 9188 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) Mr Younoos Jeetoo Mrs Kay Jeetoo Manager post vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2006 Brief Description of the Service: Cherry Lodge is a residential care home for nine adults with learning disabilities. It is a privately owned care home, located in New Malden and is close to local shops and bus or rail links. Information about the service is available in the Statement of Purpose and Service User Guide. Current fees are in the range of £590.94 to £855.08 per week. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by one inspector. The inspection consisted of a tour of the premises, examination of records and observation of care practice. The inspector met five residents, two members of staff and the manager. Feedback questionnaires were received from four residents and one relative of a person who lives at the home. What the service does well: What has improved since the last inspection? What they could do better: The new system for developing care plans and health plans must be put in place so that residents can be assured that all their needs will be met. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 6 Repairs needed throughout the home must be carried out promptly so that residents have a clean and suitable place in which to live. More must be done to empower residents and encourage them to work towards independence. This can be done through ensuring that residents have more of an input into the running of the service and the information that is written about them. Staff must be given the training they need to develop their individual skills. Training profiles must be put in place so that there is a clear programme of training throughout the year. The staff rota must be changed to make sure that there is time for handover and that there is a member of staff on duty past 8 o’clock in the evening. It would also allow for better management if the manager was made supernumerary on the rota. 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 Lodge DS0000013379.V345969.R01.S.doc Version 5.2 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 Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with good information about the service which helps them to know what to expect while living there. EVIDENCE: A copy of the Service User Guide was seen in residents bedrooms. The Statement of Purpose contains all the necessary information but must be updated with the details of the new manager. Information about the service is also available in a leaflet. All the residents have lived at the home for over two years. One person moved to a more suitable place earlier in the year. The service is able to meet the needs of all the current residents. One person whom lives there said ‘it is the first place I’ve been able to settle in’. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to be independent. However care plans must be more comprehensive so that the needs of residents can be met more fully. EVIDENCE: The care plans for each resident show how to meet individual needs. Although there is a lot of useful information it is not always easy to read or laid out in a way that makes it understandable. Action plans include personal goals such as promoting positive relationships and independence. These include action needed and a date for when it has been achieved. There was little information about personal history, culture, sexuality and relationships. There was little evidence that residents had been involved in what was written about them. The manager showed a new care plan system that will be introduced. This will provide much clearer information and a more person centred approach. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 10 Throughout the day, residents were seen to be involved in making decisions about what they wanted to do, and were confident in approaching staff if necessary. One person confirmed that there are resident meetings once a month which allow them to have their say. Risk assessments are in place to support residents to be independent but safe. These cover areas such as using the cooker, road safety and getting lost while out. These are relevant to each individuals needs. Risk assessments are kept up to date and reviewed regularly, however it is not made clear whether there has been any change after review. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents lead good lifestyles which encourage independence. EVIDENCE: All residents take part in activities of their choosing. One person said they earn small amounts of money by doing work at a day centre. This resident also enjoyed swimming, the gym and gardening. Another resident talked about a holiday to Butlins. All residents are able to go out on their own and make use of local facilities such as shops or the pub. There is still no internet access for people who live at the home, which would allow them to lead more modern lifestyles. One resident said that relatives come and visit when they want. They added that they are also able to stay at relatives some weekends. A member of staff Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 12 said that they talk to residents about relationships and there is an external organisation which offers support and advise on sexuality. Residents are aware of their responsibilities in the home and share tasks such as cooking and cleaning. Staff try to encourage residents to be independent and to resolve difficulties themselves. During the inspection, one resident was unsure about their right to travel using a Freedom Pass. This was carefully explained by a member of staff until the resident felt sure about going out. Residents take turn to cook and said that they enjoyed the food. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health of residents is promoted but must be recorded in more detail. EVIDENCE: Residents need very little personal care support but where it is required, staff help sensitively and with respect for residents dignity. All residents at Cherry Lodge are male and the majority of staff are female. This was discussed with one member of staff who said that it had not been an issue. However, it would benefit residents if there were more male staff to provide support. Resident files contained information about health and emotional needs. Health Plans are not in place, but the manager said that these will be developed. Records showed that routine health checks are carried out and there is specialist support if necessary. A pharmacy visit to look at the procedures for dealing with medication took place on 7th July 2007. A requirement was made to draw up guidelines for the use of homely remedies. The recording and storage of medication was found Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 14 to be satisfactory. Medication profiles are in place for each resident. These give information on the reasons for taking medicine, possible side effects, and any allergies. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are safe but more could be done to make sure their financial interests are protected. EVIDENCE: The complaints procedure was seen to be visible in each residents room. Residents said they would talk to the manager or staff if they were unhappy about something. The procedures must be written in a format understandable to all residents so that they are aware of the process for making a formal complaint. The way that complaints are recorded does not make the original complaint clear and outcomes are not recorded. Money held on residents behalf is monitored to make sure there are no errors. Receipts are kept and tally with amounts recorded. One resident was seen signing the book after they had taken some money and it was explained to them what they were using the money for. The service must ensure that residents interests are properly protected where there are large amounts of money kept by others on their behalf. One person has money held on their behalf by trustees but is not always able to use it as they wish. This must be raised with the care manager. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 16 Procedures are in place for the Protection of Vulnerable Adults (POVA) and staff have received refresher training in POVA over the last year. There have been no recent complaints or allegations. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Communal areas are homely but minor repairs must be carried out promptly to improve the environment. EVIDENCE: Cherry Lodge is laid out over three floors. On the ground floor there is a bright, clean lounge and dining area which has been made homely with pictures of residents around the room. The kitchen is clean and well equipped, however the strip light was without a cover and a pull switch was covered in grease and dirt. There is a large, well maintained garden to the rear which is enjoyed by residents. The shower room would benefit from redecoration. On the first floor, there is a pleasant bathroom and separate sleep-in area for staff. There were two more lights without covers on this floor and one light in the corridor was not working. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 18 Resident bedrooms were seen to be personalised with pictures and posters. One resident showed me they had a TV and Playstation. One bedroom had been painted recently but there was a bare patch by the window and the ceiling was stained. Another resident showed me their room and was unhappy that the window did not close properly and that they were unable to turn the radiator on and off. The manager said this had all been reported. The carpet in the room had also been badly laid and was coming up in places. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff are competent in their roles but would benefit from more consistent training. EVIDENCE: There is small but experienced staff team at Cherry Lodge. During the inspection staff on duty were observed to get on well with residents and were knowledgeable about individual needs. Feedback from residents was positive about the care they receive. Rotas show that after 8pm there is only a sleep in member of staff available, who is not required to be on duty. This does not provide sufficient support to residents. Although handovers do happen there is no time set aside for this on the rota. Recruitment monitoring forms are in place which show that staff have all the necessary checks in place. However there was not a photograph of each member of staff and some Criminal Record Bureau Disclosures are over three years old. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 20 Training attended by some staff over the past year includes moving and handling, epilepsy and empowerment. However, training plans for individual staff are inconsistent. One staff had a training plan but it was not dated, another person plan was out of date. The manager is keen to get everyone up to date with training, in particular medication and person centred planning. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager is keen to make improvements to the service which will benefit the people that live there. EVIDENCE: A new manager has been in post for six weeks. She has plenty of experience of management in care work and was keen to discuss how the service can be improved. Despite being in the post for a short while the manager has a good understanding of each resident’s needs, and of the strengths and weaknesses of the service. The manager is supported by a consultant who meets with her every week. The manager is included on the rota and is expected to take part in shifts which does not support her to run the home effectively. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 22 Resident meetings take place once a month and give people who live at the home an opportunity to out their views forward. However, monthly monitoring visits are not taking place regularly. Residents are occasionally asked to fill in questionnaires as part of quality assurance within the service. One of these was seen dated October 2006. The questionnaires are not user friendly and must be updated to make them more meaningful to residents. It must also be made clear what action has been taken as a result of any feedback. Health and safety checks are mostly up to date, including gas safety, portable appliance testing and electrical installation. However, information on hazardous chemicals must be updated. Fire drills take place regularly and the fire system was serviced in May 2007. A fire risk assessment should have been updated in April 2007 but is still to be completed. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 24 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. 1. Standard YA1 Regulation 6 Requirement Timescale for action 15/09/07 2. YA6 YA8 3. YA19 So that prospective residents have accurate information the Statement of Purpose must be updated to include the current managers details. 15 To ensure that residents needs are fully met, care plans must include information about personal history, sexuality and cultural background. Residents must be consulted in how care plans are written. 12(1)(2)(3) To ensure that the health needs of residents are fully met, comprehensive and up to date Health Plans must be in place. 22 So that residents are clear about the process, the complaints procedure must be in an easy to read format. Complaint investigations must be clearly recorded and include outcomes. To empower residents, action must be taken to ensure their financial interests are properly protected, particularly where large amounts of money are held on their behalf by others. DS0000013379.V345969.R01.S.doc 01/10/07 01/10/07 4. YA22 01/09/07 5 YA23 13(6), 12(1) 01/09/07 Cherry Lodge Version 5.2 Page 25 6 YA24 YA25 YA30 YA32 23, 16(2)(c) 18(1)(a) 7 8 YA34 Schedule 2 9 YA35 18(1)(c) 10 YA39 24 11 YA39 26 12 YA42 13(4) To improve the environment for residents, all concerns about the premises highlighted in this report, must be rectified. To ensure there is sufficient support for residents, staff must be on duty until a reasonable time in the evening and handover time must be included as part of the rota. To ensure that recruitment is fully safe, a photograph of each member of staff must be kept at the home. To make sure that staff are trained appropriately, up to date training plans must be in place. To make sure residents are properly consulted, any quality assurance questionnaires must be user friendly and any action taken as a result of such feedback must be made clear. To make sure there is effective monitoring of the home, monthly visits must take place and a report be kept at the home. To ensure that all parts of the home are free from risk, information on hazardous chemicals must be updated and the fire risk assessment must be reviewed. 01/10/07 01/09/07 01/09/07 01/10/07 01/10/07 01/09/07 01/10/07 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 YA12 Good Practice Recommendations Internet access should be provided to residents to allow for better access to information and communication networks. DS0000013379.V345969.R01.S.doc Version 5.2 Page 26 Cherry Lodge 2 3 4 YA18 YA33 YA34 YA37 It would be beneficial to residents if there were more male members of staff in the team. To better protect residents, Criminal Records Bureau Disclosures should be renewed every three years. To enable more effective management the manager should be supernumerary on the rota. Cherry Lodge DS0000013379.V345969.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Lodge DS0000013379.V345969.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!