CARE HOME ADULTS 18-65
Cherry Lodge 14 Lynton Road New Malden Surrey KT3 5EE Lead Inspector
Michael Stapley Key Unannounced Inspection 16th May 2006 09:30 Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 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 Mrs Tracey Pope-Warren Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th October 2005 Brief Description of the Service: Cherry Lodge is a residential care home for nine adults with learning disabilities. It is located in New Malden, close to local shops and had good transport links with trains to London and buses to Kingston Town Centre and other surrounding areas. The Registered Persons have produced a Service Users Guide that includes the aims and objectives of the home. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day on 16th May 2006. The home was represented by the Registered Manager, Mrs. Tracey PopeWarren and support staff who all contributed to the inspection process. The manager is supported by Mike Hale who is the consultant to Carewatch Limited the company that manage the home. He too is very experienced and well qualified to support the manager in her day to day management of the home. Records examined included service user plans; care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Previous requirements and recommendations were discussed with the registered manager who will be sending an action plan to the commission as agreed at the time of the inspection. What the service does well:
Service users are very much the centre of attention in the home; all of them have a programme of day care. The home seeks to promote the independence of service users and ensure equality of service. All of the service users have resided at the home for some time and since the last inspection have become far more involved in the running of the home. Individual care plans are very comprehensive and headings include a pen picture of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of the local pharmacist for advice on medication. Staff members have access to a range of training courses to build on their skills to ensure that they are able to meet the service users assessed needs. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection?
The registered manager, Mrs Tracey Pope-Warren commenced her duties at Cherry Lodge on 17th October 2005. She is an experienced manager who is a qualified nurse who has a wealth of experience in working with adults with learning disabilities. In the nine months she has been at the home she has begun to address shortfalls within the home. In discussion with the inspector it was evident she has plans to involve the parents and relatives in the home far more. She has been involved in developing the staff training programme and reviewing Person Centred Care Plans. Perhaps one of the most important areas of development is that staff at the home are now becoming far more involved in the day-to-day organization of the home. Monthly reports for service users have been introduced are compiled by the service user’s key worker and used as a tool to evaluate each individual service user’s progress. A new format for staff supervision has been introduced although supervision is currently not taking place in line with the required standard. Service user’s questionnaires have been drawn up and are shortly to be distributed. The responses from the service users will be discussed at monthly service users meetings and the home is beginning to address some of the issues that have been raised. Staff meetings at the home are used as a tool to improve communication amongst the team and discuss basic care values. The home has a complaints procedure both in written and pictorial form which has now been develop in the form of a video. However the inspector expressed concern that the complaints log was in a loose leaf file and suggests that this is replaced by a hard back book to ensure entries do not go astray. Any complaints made should give details of any investigation, action taken and the outcomes. See standards 22 23 for further comment. There have been improvements in the environment with refurbishment and redecoration having taken place. Contracts for service users now contain all the information required under standard five. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 7 What they could do better:
Notwithstanding the appointment of Mrs Tracey Pope-Warren who is now the registered manager of the home it is noted that she is the third manager of the home within the last nine months. The registered providers must ensure in so far as is practical that there are no further management changes. This is essential if the home is to develop sound working practices and have a clear vision for the future. The home does not have a deputy manager and has a small group of core staff who are supported by bank and part-time staff. The activity programme for service users needs to be further developed. While most of the service users are independent there is a need to increase the range and choice of activities on offer at the home. This is clearly somewhat difficult given that the home does not receive an allowance from the managing company for activities. Service users are expected to pay for any activities they wish to undertake. In addition the home does not provide an annual holiday for service users as laid down in Standard Fourteen. However it was noted that all of the service users had recently returned from a long weekend in Chichester. Service users would also benefit from having the use of a computer and internet connection for both educational and leisure pursuits. There is also a need to ensure that all staff have received Adult Abuse training as it was evident that not all staff had. The inspector was concerned to note that the home had still not had an assessment from an Occupational Therapist for aids and adaptations. Given that the home has two service users who have a physical disability as well as a learning disability they must make arrangements for this assessment to take place without further delay. Recommendations from any report must also be put into place to ensure equality of service for all service users. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 8 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 Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 9 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.V294036.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users contain all the information required thus ensuring the rights of the residents of Acorn Lodge. Staff at the home have access to a range of training programmes thus enabling them to offer an effective care programme for service users. EVIDENCE: The home has a preadmission procedure including a resident’s charter. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. Senior staff at the home can visit the prospective service user in their current placement or own home, if appropriate. The importance of any service user coming to the home and relating to those already living at the home was clearly emphasised. A number of introductory visits are planned; this may include an activity and a meal at the home. In addition overnights stays can be arranged to ensure the service user is at ease when they come to their new home. It is clear that although this admission process takes some time it does give every chance for the new service user to settle in to their new surroundings and thus give a solid grounding to any placement. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 11 Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. All of the service users at Acorn Lodge have lived at the home for some time and in discussion with the staff it was evident that assessment is on going and is seen as very much part of the care plan. Personal Care plans are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. The home monitors service users care plans on a six monthly basis although information is up dated and care plans reviewed when significant events occur. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The manager advised the Inspector she was in the process of reviewing service users assessments in conjunction with the local community team for people with learning disabilities. Three service users had so far been referred to this service which help to give an updated picture of the current needs of the service users at the home. The manager advised that only one service user currently had access to an advocate which was for the local authority. The cost of advocacy is not included in the homes fees and therefore the manager has to seek alternative services for those who need independent support. The manager of the home advised that she was currently seeking to resolve this issue which will need to be reviewed at the next inspection. The home has a training programme that has been reviewed. This includes Person Centre Care Planning, Working with Adults with Challenging Behaviour and Mental Health Dual Diagnosis. There is a need to ensure training updates occur on a regular basis particularly in respect of Adult Abuse, Fire and Manual Handling. Contracts for service users have been revised and now contain all the information as required. thus ensuring service user’s rights. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Service user care plans contain all the information required as per standard six. Staff at the home have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker who writes a monthly report on his/her service user. It is suggested that service user’s could have their own personal file written in a format they understand which they keep could and refer to.
Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 13 The home is beginning to be far more service user focused. Service users are encouraged to become far more involved in the home. House meetings that take place every four weeks are used as a communication tool to empower service users. Service users files sampled at random during this inspection all had individual risk assessments and risk management strategies. Risk assessments inspected during the course of this inspection were all found to be up to date. Service users are encouraged to make their own decisions within the context of risk assessment wherever possible. All service users have individual choice although it would be beneficial if service users could have access to an independent advocate when required. The manager advised that she was currently attempting to address this issue. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. The daily routines and house rules promote residents’ rights and encourage independence. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: The home is supporting service users to access appropriate activities through the activity programme. The service users access local parks, cafes, theatres, local leisure facilities and shops. In addition to swimming and other sporting activities. However as the home does not receive any form of allowance for service users activities from the managing company this does somewhat restrict the range of activities on offer. In addition the home does not provide an annual holiday for service users as laid down in standard fourteen. The home has its own people carrier which makes accessing activities a great deal easier, although the inspector was advised this vehicle was used by all three of
Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 15 organisation’s homes and was usually based at another home. The Staff team are available to support service users while accessing community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. The inspector, in discussion with the manager suggests it might be prudent for service users to have access to computers and the internet to enhance the social and educational skills. Any software would clearly need to be suitable and accessible to those with a disability. The manager stated she would welcome such a facility so she and the staff could produce posters, improve the quality of Person Centred Plans and use such a software programme as Widget to enhance the quality of communication for the benefit of service users. Service users spoken to also advised the Inspector this would help with their Education and Day Care programme. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. Parents, relatives and friends are encouraged to visit the home whenever possible. Any restriction on visitors or who a service user may visit would only be taken after discussion with parents, relatives and/or care managers and recorded on file. In addition all service users have a front door key if they wish although the manager advised some of the service users do have a propensity to loose keys – in which case they would be expected to pay for a replacement. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. EVIDENCE: Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. One of the service users self medicates at lunch time while attending a day centre. There was no evidence to suggest a risk assessment had been completed for this service user in respect of self medication. A risk assessment must be completed for any service user prior to the commencement of self medication. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 17 All of the staff team save for one have now completed accredited medication training. The pharmacist visits the home on a regular basis. All requirements and recommendations from the inspection of 19th December 2005 have been complied within laid down timescales. All other medication records, including MAR sheets and service user profiles were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. The manager now audits all aspects of medication on a weekly basis. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a detailed complaints procedure. A pictorial format of this procedure has been developed and provided to service users. The Inspector noted that any concerns appeared to centre around one particular service user and his unacceptable behaviour. The manager advised how she dealt with these situations including on occasions calling a house meeting to discuss these issues. During the inspection the inspector spoke to the service user about aspects of his life at the home including his challenging behaviour. All complaints were managed appropriately. However the complaints file was in a loose leaf file. The inspector suggests it would be more appropriate if any complaints were recorded in a hard back book. There had been no complaints since the last inspection. The manager is advised of the importance of thoroughly investigating all complaints and recording details any action taken and the outcomes. There are also policies and procedures in place regarding the protection of vulnerable adults. The home has drawn up a flow chart to ensure that all staff is aware of the action to be taken in regard to adult protection. The staff team are aware of the action they must take if they need to report an incident.
Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 19 The Inspector noted that not all of the staff team had undertaken adult protection training. The manager agreed to arrange such training within agreed timescales. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: The home is a two story building in a residential road. It is situated in New Malden and is close to local shops and amenities. There is a large communal lounge on the ground floor as well as a kitchen/dining room. The furniture is domestic, flame retardant, and of reasonable quality. Service user’s bedrooms provide privacy and reflect individual interests and preferences. However the Inspector noted that service users did not have individually controlled heating in their bedrooms as stated in the National Minimum Standards. The home does not have a lift – one of the service users is not able to use the stairs – her bedroom is down stairs and she is able to use the downstairs bathroom. However she is not able to able to access the rear garden from the
Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 21 dining room as there is not a ramp. Instead she has to go around the side of the house to access the garden. The managing company has still not arranged for the home to have an assessment by an Occupational Therapist for aids and adaptations for those two service users that have a physical disability. This assessment must be completed without further delay. The Inspector was advised that there is a lack of facilities for staff to store their personal belongings when on duty. The managing company must ensure such facilities are made available for staff as outlined in the National Minimum Standard. There has been some improvements in the décor of the home since the last inspection and there is an ongoing programme of planned refurbishment. Since the last inspection some of the carpets have been replaced throughout the home. The home was very clean and hygienic and free from offensive odours through out on the day of the inspection and systems are in place to control infection in accordance with relevant legislation and published professional guidance. Laundry facilities were found to be reasonable and although the laundry floor finishes were not impermeable. The home has thermostatic valves fitted to the bath to avoid any scalding accidents. The temperature of the water is taken and duly recorded. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. The staff team have access to a wide range of training programmes which enhance their personal and professional development. EVIDENCE: The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist training courses such as that offered by BILD for staff who work with service users who have a disability New members of staff complete an induction and foundation programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The inspector noted that the induction programmes for staff are signed dated and kept on staff files. The manager has undertaken a training needs assessment for all of the staff team although staff do not have an individual training and development
Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 23 assessment profile. Evidence was available of an NVQ training programme and when staff have completed this training the home will have above fifty per cent qualified to at least NVQ level 2. Criminal Records Checks are completed before a new member of staff can begin work in a home and recruitment procedures are now far more robust than at the last inspection. The manager offers professional support to the support workers in addition to bank staff. She is currently responsible for the supervision of junior staff which although taking place is not in line with standard 36. The manager advised that staff meetings usually take place every four weeks. They are used as a communication tool, where information is shared and common themes are addressed. Staff meetings minutes evidenced were clear and focused on service users needs. There are two staff members on duty on each shift, plus one member of staff sleeping-in. There are suitable on call arrangements in place in case of an emergency. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: The manager offers support and supervision to the support workers at the home. There are good support mechanisms in place and the manager meets with the responsible individual and homes consultant to discuss any issues concerning the home, efforts are made to meet any concerns or improve the service. The managing company must ensure regulation 26 reports are available at the home and a copy must be sent to the registered manager. The manager of the home as not undertaken the Registered Manager’s Award and she will need to commence this course within an agreed timetable. In addition the manager advised the Inspector that she would like to obtain the NVQ assessors award – D1 and D2. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 25 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are up to date and a fire risk assessment has been completed. The residents are beginning to benefit from a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties has been reviewed. The quality assurance system includes service user, relatives, staff and outside professional questionnaires. The home is shortly to complete a survey for service users, care managers, families and other stakeholders. The home will need to collate the results of these surveys and will need to evidence that the results of the surveys are acted on for the benefit and wellbeing of the service users at the home. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 2 29 1 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 2 Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 27 YES. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 5 Requirement The registered person must ensure that service users in long term placements have as part of the basic contract price the option of a seven day holiday outside of the home, which they help choose and plan. The registered person must ensure that any service user who self medicates has an up to date risk assessment The registered person must ensure all staff have received Adult Ause training. The registered person must ensure all maintanance issues that were highlighted at this inspection – including cracked/broken windows and window handles are repaired. The registered person must ensure that all service users’ bedrooms are lockable. The registered person must ensure that all service users’ bedrooms having heating that can be individually controlled. The registered person must ensure must ensure that staff are provided with adequate
DS0000013379.V294036.R01.S.doc Timescale for action 31/07/06 2. YA20 12 13 19/05/06 3. 4. YA23YA23 YA24YA24 13 23(b) 31/07/06 31/07/06 5. 6. YA26.4 YA26.2 23 23 31/07/06 31/07/06 7. YA28 23(3) 31/07/06 Cherry Lodge Version 5.1 Page 28 8. YA29 23(2) 9. 10. YA30YA30 YA35 13(3) 16(2)(j) 18(1) 11. YA35.5 18 12. YA36YA36 18(2) 13. YA37YA37 18 14. 15. YA39 YA39YA39 24(1) 24 facilities including a safe place to store personal belongings. The Registered Provider must ensure that a suitably qualified professional such as an occupational therapist, assesses the service users concerned, the home providing aids, adaptations and equipment as recommended, specifically to address transfers from chairs, use of the stairs, and access to the garden and front door. (Not met at 31/12/05) The registered person must ensure that the laundry floor finishes are impermeable. The registered person must ensure all staff receive equal opportunities training, race equality and anti-racism training (Partly met at 31/12/05 – but two staff still need to complete this training) The registered person must ensure all staff have an individual training and development profile. The registered person must ensure that all staff have supervision in line with standard 36 to include all elements of 36.4 The registered manager must enrol and provide evidence that she is studying for the Registered Managers Award. The registered person must ensure that an internal audit takes places at least annually. The registered person must ensure the home has an effective quality assurance system in place to ensure the home is meeting is stated aims and objectives. This should include surveys of service users, stakeholders and other
DS0000013379.V294036.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 Cherry Lodge Version 5.1 Page 29 16. YA43YA43 26 interested parties, the results of which must be sent to the CSCI, local office and the registered person must ensure that an annual audit of the home takes place at least once a year. (Requirement partly met at 31/12/05) The registered provider must ensure that monthly visits are made to the home and a report sent to the commission and registered manager. 31/07/06 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. Refer to Standard YA7YA7. YA37YA37. Good Practice Recommendations The registered provider must ensure that service users have the option of an advocate if needed. It is strongly recommended that the registered manager attends an NVQ Assessors Course. Cherry Lodge DS0000013379.V294036.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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