Inspection on 25/10/06 for Cherry Lodge

This inspection was carried out on 25th 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 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 13/07/07

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

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Edenvale

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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 Michael Stapley Key Unannounced Inspection 25th October 2006 09:30 Cherry Lodge DS0000013379.V317170.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.V317170.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.V317170.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 Mrs Tracey Pope-Warren Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 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.V317170.R01.S.doc Version 5.2 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 Thursday, 26th October 2006. The home was represented by the Registered Manager, Mrs. Tracey Pope-Warren 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: • The staff team - The staff team at the home are very positive about the work they undertake with the service users. Staff commented on the opportunities that are available for service users, this was reflected in discussions with service users at the home. Staff Meetings - The home has staff meetings every month and these meetings are used to improve communication amongst the team and discuss basic care values. Staff members continue to improve their skills and knowledge by attending a number of different training courses. Care plans - These are reviewed and monitored in consultation with service users, their families and representatives and are reviewed every six months in line with standard 6.10. In addition Person Centred care plans have been introduced for all service users. Most of the staff has received appropriate training in order to facilitate such plans although in DS0000013379.V317170.R01.S.doc Version 5.2 Page 6 • • Cherry Lodge discussion with the manager it was evident this needed to be updated. The home has a complaints procedure both in written and pictorial form although slight amendments are needed. What has improved since the last inspection? Service user guides / guides / statement of purpose – these have been reviewed and improved. i PCP targets and goals – the home have achieved a number of goals and aspirations identified by service users within their own PCP meetings these are continuously reviewed and personal goals and targets are reviewed. NVQ trained staff – Since the last inspection a number of staff have completed their NVQ and a further number have commenced their NVQ training. Shift cover – The home has a full team and therefore does not need to use agency staff to cover shifts at the service. This means continuity of care and service delivery for the service users. Communication – Because the home now has a full team there is better communication and consistency of approach and a greater commitment to communication. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 7 What they could do better: • • Ageing and Death – The home needs to ensure it has discussed and recorded the wishes of service users as outlined in Standard 21. Networking and share knowledge – Now that the home has a full team they need to expand their networks and share there knowledge with other local providers as well as gain from their experience. ICT service users – The home could support service users in gaining and developing an interest in computers by purchasing a computer and using software that has been designed to be easily useable and understandable. The home could focus on the development of service user’s independence through simplistic tools to enable individuals to gain greater opportunities in a self-directive lifestyle. The home could do better by ensuring all environmental issues and requirements are dealt with effectively and efficiently. The home could do better by ensuring that those service users with a physical disability have the appropriate aids and adaptation they need to ensure equality of service. The home could do better by ensuring that arrangements are in place for the pharmacist to visit and inspect the home on at least an annual basis. • • • • • Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 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.V317170.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 do not contain all the information required under standard five thus the rights of the residents of Cherry Lodge could be at risk. Staff at the home have access to a range of training programmes thus enabling them to offer a reasonably effective care programme for service users. EVIDENCE: The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. 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 Cherry Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 11 Lodge had a clear process of introduction to the home according to their individual needs. The registered manager advised that assessment is on going and is seen as very much part of the care plan. Person centred care plans that are gradually being introduced 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. These are in an appropriate format for the service users currently at the home. They are user friendly easy to read and contain photographs of service users, family, friends and significant events. The manager has recently introduced a ‘How to support me by me’ plan for all service users. This clearly sets out how individual service users wish to be supported while at the home and gives a clear picture of what support they need. In addition service users have their own ‘Personal Planning Book’ which is updated on a regular basis and is unique to each service user. The home carries out internal six monthly reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The home has a reasonable training programme including NVQ training. The training programme includes first aid, health and safety, medication, person centred care plans, fire awareness training and more recently mental health/dual diagnosis. The registered manager advised the inspector that future training includes epilepsy, key working, risk assessment, widget, and death and dying. While this is to be commended the home could expand this training programme to include specific reference to those with learning disabilities has offered by BILD. The home has developed an in depth Statement of Purpose which is reviewed on a regular basis in the light of changes to legislation and the needs of the service users. The Statement of Purpose includes all elements of regulation 4 including the skills of the staff team and their experience and how these can meet the needs of service users. All of the service users at the home have a contract/statement of terms and conditions. However this does not contain all elements of Standard 5.2 namely the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of the Service Users Plan, and clearly states that there will be a ninety day trial period. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 12 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 13 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user care plans contain all the information required as per standard six. Staff at the home has 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 and evidence of key Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 14 working was duly noted where appropriate. The home has become far more service user focused. Service users are encouraged to become far more involved in the home. House meetings are service user led and support is given to establish opportunities for training at local colleges or day centres where appropriate. The registered manager explained that the home has moved towards Person Centred Plans where ownership of the plan is given to the individual service user. In addition staff most of the staff at the home had attended Person Centred Planning training at the time of the inspection. Service users files sampled at random all had individual risk assessments and risk management strategies. Service users are encouraged to make their own decisions within the context of risk assessment. All service users have individual choice and the home provides an independent advocate for individual service users where desired, in addition it is evident that service users are empowered through group meetings and key working. The home has a confidentiality policy that is available to service users and their respective families. Service users, their families and representatives are aware that all information about them is handled in a sensitive manner and that confidences are kept. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 15 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 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. 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: During the inspection there were two service users at the home. One of the service users spent time talking to the inspector about his wishes and aspirations. He explained that he would like the home to have a computer not only for educational but recreational use. At present the home does not have a computer or internet facilities and the inspector suggests this is given due Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 16 consideration. Overall the two service users spoken to were reasonability content with the service being offered. The registered manager and staff were observed to interact with the service users in a positive manner. There was awareness from the staff that the service user’s privacy and individual choice must be maintained. The service users were observed moving freely throughout the communal areas although comment is made under standard 29 about the lack of appropriate aids and adaptations for one service user whose movement is somewhat restricted. The home supports service users to access appropriate activities such as swimming, sports and leisure activities and making use of the library. In addition service users have access to local parks, cafes, theatres and shops. Service users spoken to stated that they enjoyed the activities on offer at the home although it is clear they could be expanded. The manager advised that this has proved difficult as the activities budget is only £10 per week for the home for up to nine service users and staff. Service users are therefore expected to pay for activities themselves and this has proved difficult given the majority are on state benefits. It is therefore suggested that consideration be given to increasing the activity allowance to a far more reasonable amount. Service users at the home have an annual holiday; the inspector was advised that the cost of a minimum seven day holiday is not included in the contract as the expectation is that service user pay for the cost of the holiday. The registered manager has written to the placing authorities to seek such funding. It is also suggested that this element of standard 14 be built into the contract of any new service user. The registered manager advised the inspector that the home had started a ‘savings scheme’ for holidays and in addition the registered provider provides a grant towards the cost of holidays. Some of the service users have aspirations about taking holidays abroad. The manager advised the inspector that due to funding this would pose difficulties. Parents, relatives and friends are encouraged to visit the home whenever possible. Service users have access to educational facilities, although as stated earlier they do not have access to a computer or the internet. 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. Both of the service users said that they enjoyed what they had to eat at the home. The home has access to its own shared vehicle and also uses community transport. The registered provider is currently considering purchasing a dedicated vehicle for each of the three homes he manages. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 17 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 18 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 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. The home has yet to establish an up to date record of the service user’s wishes at death thus appropriate arrangements may not be made. 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. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 19 The registered manager advised the inspector that one of the service users self medicate. A completed risk assessment had been duly completed for the service user who self medicates and all medication was appropriately stored. The home has appropriate medication policies and procedures. All service users have a ‘Medication Profile’ All of the staff team have now completed accredited medication training. The pharmacist last visited the home on 19th December 2005. All requirements and recommendations from that inspection of have been complied with However due to a change in local procedures the homes pharmacist will know longer be visiting the home or carrying out any inspections. The registered manager has agreed to seek information and advice from the pharmacist by means of letter or telephone as laid down in element twelve of standard twenty. The inspector suggests that the registered provider considers purchasing pharmacy visits/inspections to ensure the welfare of service users. 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 wishes of service users regarding death and dying have as yet not been clearly identified and recorded. The manager advised that she is in the process of drawing up a template for this to be recorded. It is suggested that some of this should be in a pictorial format. This will help support service users and their families to record their wishes at the time of their death. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 20 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 which has been updated to include all the necessary information that service users, relatives and other parties may need to make a complaint. However it does not give details of any investigation, action taken and outcomes which must be duly recorded. The procedure is formatted with pictures and photographs so that it is more accessible to those who cannot read. Service users spoken to were clear about whom they would go to if they were unhappy and felt comfortable to raise any concerns. The Registered Manager said that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. The registered manager advised the inspector that all staff had now undertaken POVA training by an accredited trainer. The Royal Borough of Kingston’s Suspected Abuse of Vulnerable Adults Policy is in place and the home also has its own policies on adult protection, whistle blowing and Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 21 management of service users’ finances. In addition recruitment practices are generally secure to ensure that people are protected from unsuitable staff. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 22 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, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean although there are a number of environmental issues that have not been dealt and the home has not had an assessment for aids and adaptations for service users with a physical disability. 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. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 23 Service user’s bedrooms provide privacy and reflect individual interests and preferences. However the Inspector noted that service users still 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 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 registered provider advised the inspector that he would be personally contacting the relevant authority to ensure this assessment is carried out. There have been some minor improvements in the décor of the home since the last inspection although there is not a planned programme of maintenance and refurbishment. A requirement made at the last inspection highlighted a number of broken/cracked windows that were in need of repair. At the time of this inspection this requirement had not been complied with. In discussion with the registered provider it was stated that this would be addressed without further delay. In addition the inspector noted what appeared to be ‘damp’ in a number of areas in the home. The registered provider must investigate this and ensure this is rectified without delay and confirm to the commission when this work has been completed. Some of the house needs decoration and some furnishings are looking ‘tatty’ In addition some of carpets and curtains require replacement. Comments were made by care management and families at a recent meeting regarding these issues so clearly they are issues of concern. The registered manager advised that she had submitted an estimate and schedule of works to the registered provider and was waiting for the finance to be approved. The home was 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 the laundry floor finishes were now 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.V317170.R01.S.doc Version 5.2 Page 24 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 25 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. 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. The inspector noted that all of the staff had now undertaken disability equality training, race equality training or anti-racism training. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 26 New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. Criminal Records Checks are completed before a new member of staff can begin work in a home. Staff files are not kept at the home but are held at the head office of the managing company. The registered manager must ensure that a CSCI pro forma is completed for each and every member of staff working at the home which should be available for inspection as and when requested. In addition the registered manager must evidence that staff are physically and mentally fit to work by obtaining proof of health clearance. The home has a small but experienced staff team consisting of registered manager and support workers in addition to regular care bank staff. The registered manager is supported by an experienced and qualified external consultant who also offers regular supervision. There are always two members of staff on duty who also undertakes sleepingin duties. There are suitable on call arrangements in place in case of an emergency. The inspector evidenced that a training plan was in place for Cherry Lodge. In addition the registered manager has introduced an annual appraisal for all staff. The training needs for staff are identified during the annual appraisal and duly recorded following which arrangements are made for staff to attend such training. In addition all staff who is employed at Cherry Lodge has an identified training plan. However the home does not have a dedicated training budget as outlined in standard 35. The registered manager advised the inspector that she had recently received a grant from the workforce, training and development council for £1000. The inspector noted that all staff at Cherry Lodge is now receiving supervision at least six times each year. The supervision format is comprehensive and contains all elements of standard 36.4 Records seen during the course of this inspection were signed and dated by the registered manager and member of staff. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 27 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 28 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 registered manager offer support and supervision to the support workers at the home. There were good support mechanisms in place and the manager meets with the homes consultant of the managing company to discuss any issues concerning the home, efforts are made to meet any concerns or Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 29 improve the service. The home does not; as yet have an annual development plan and business plan for 2006-07, a copy of which must be sent to the commission when duly completed. The managing company ensure all records are in place by completing monthly regulation 26 reports although these reports are not sent to the commission as per regulation. A requirement has therefore been made that copies of the next three monthly reports be sent to the commission. 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 had 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 is reasonable. The quality assurance system includes relatives, staff and outside professional questionnaires. When all these have been received and been finalised the results will be collated and any issues from these and other questionnaires will be addressed. The home will need to evidence that the results of theses surveys are published and acted on for the benefit and wellbeing of the service users at the home. In addition the registered person must ensure that the home as an internal audit at least once a year. All policies and procedures that are relevant to service users are now in a suitable format including complaints, service user guide and details of chores service users are expected to undertake. All certificates in respect of health and safety were evidenced during the course of this inspection. Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 30 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 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 1 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X 2 3 X Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 Requirement The registered provider must ensure that all service users contracts contain all elements of standard 5.2 The registered person must ensure that all service users’ bedrooms having heating that can be individually controlled. Requirement not met at 31/07/06) The Registered Provider must ensure must ensure that the complaints procedure is amended to include all elements of standard twenty two and that the complaints record is monitored at least every three months. The registered person must ensure all maintenance issues that were highlighted at this and the last inspection - including cracked/broken windows and window handles are repaired. The registered provider must send to the CSCI, local office an ongoing maintenance and development programme DS0000013379.V317170.R01.S.doc Timescale for action 30/11/06 2. YA7 23 30/11/06 3. YA22 22 30/11/06 4. YA24 23(b) 30/11/06 5. YA24 23 30/11/06 Cherry Lodge Version 5.2 Page 32 6. YA24 23 7. YA29 23(2) regarding the renewal of the fabric and decoration of the home both internally and externally. The registered provider must 30/11/06 arrange for the areas of ‘damp’ within the home to be investigated and made good without due delay. The Registered Provider must 30/11/06 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 addressing transfers from chairs, use of the stairs, and access to the garden and front door. (Not met at 31/12/05 and 31/07/06) The registered provider must 30/11/06 ensure that staff records “ are at all times available for inspection in the care home by any person authorised by the commission to enter and inspect the care home” (As an alternative the home may complete a staff pro forma available from the commission) The registered person must 30/11/06 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 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 31/07/06) 8. YA34 17 4 9. YA39 24 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 33 10. YA41 26 The registered provider must ensure that monthly visits are made to the home and send the next three monthly (Nov, Dec and Jan 2007) reports to the commission and registered manager. 30/11/06 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. Refer to Standard YA14 Good Practice Recommendations It is strongly recommended that the registered provider 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. It is strongly recommended that service user’s wishes concerning terminal care and death are discussed and duly recorded. It is strongly recommended that all staff receive specialist training such as that offered by BILD or other specialist trainer as part of their individual training and development plan. It is strongly recommended that all staff undertake PCP training as part of their individual training and development plan. It is strongly recommended that there is an annual development plan for the home, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. 2. 3. YA21 YA35 4. 5. YA35 YA39 Cherry Lodge DS0000013379.V317170.R01.S.doc Version 5.2 Page 34 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. 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