Inspection on 02/07/07 for Cherry Lodge Rest Home

This inspection was carried out on 2nd 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cherry Lodge Rest Home 29/01/08

Cherry Lodge Rest Home 29/10/07

Cherry Lodge Rest Home 31/05/06

Cherry Lodge Rest Home 29/09/05

Cherry Lodge Rest Home 08/07/05

Cherry Lodge Rest Home 07/09/04

Cherry Lodge Rest Home 05/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cherry Lodge Rest Home Cherry Lodge 75 Whyteleafe Road Caterham Surrey CR3 5EJ Lead Inspector Susan McBriarty Unannounced Inspection 2nd July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Lodge Rest Home Address Cherry Lodge 75 Whyteleafe Road Caterham Surrey CR3 5EJ 01883 341471 01883 347706 cherrylodge@hotmail.com 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) Mrs Cherie Margaret Callender Mrs Cherie Margaret Callender Care Home 14 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (14), Physical disability (1), Physical disability over 65 years of age (1) Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: OVER 65 YEARS, with one person in the category PD who may be in the age range 60 to 65 The age/age range of the persons to be accommodated will be: OVER 65 YEARS, with one person in the category PD who may be in the age range 60 to 65 years Of the service users accommodated up to 6 may be in the category Mental Disorder (Older Persons) MD(E) and/or Dementia (Older Persons) DE(E). Of the service users accommodated one person may be in the category Physical Disability (Older Persons) PD(E) 31st May 2006 2. 3. Date of last inspection Brief Description of the Service: Cherry Lodge is able to provide accommodation and care for up to fourteen (14) older people. Some of the people living at the home may also have a mental disorder or dementia. The home is a large detached property located in Caterham, Surrey and accommodation is provided on two floors accessed by a stair lift and comprises of an office, lounge, dining area, kitchen, laundry room, toilets, bathrooms, showers, ten single and two double occupancy bedrooms. The home has a large garden to the rear of the property that is well maintained, private and secure with wheelchair access. The home is close to the local shops and amenities. Limited parking is available to the front of the home. Fees for 2007 are £545 to £565 per week for a single bedroom and £525 per week for a shared bedroom. The home welcomes queries from local authorities regarding funding levels. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the second key inspection carried out by the commission. The inspection took place over seven (7) hours, commencing at 10:00am and ending at 5:00pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The manager was available throughout the inspection and a senior member of staff also assisted the commission. The inspection took into account records held at the home including residents’ files, staff personnel files, training, medication administration records and care records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents, visiting relatives and staff. One comment card was received from a resident. The Annual Quality Assurance Audit (AQAA) had not been completed by the home as required by the commission. Four (4) copies had been emailed to the home, the manager said that one had been deleted due to confusion over whether or not they should have received one at that time, two had not been received and the fourth was sent on the 28th June 2007. The manager was advised that the completed AQAA must be with the commission by the 9th July 2007. The AQAA was received by email on the 9th July 2007. On the 7th June 2007 the commission asked the home for a list of relatives and stakeholders in order that surveys could be sent to the named individuals to make sure any feedback received could be used in the inspection report. The list was received on the 2nd July 2007 during the visit to the home by the commission. Any feedback received before this report is made final will be included. What the service does well: Feedback received during the visit from relatives and people who use the service said that the members of staff were kind and helpful. Those relatives spoken with said that they could visit at any time and were made welcome, one said they were always offered a hot drink. Building work was taking place during the visit and the home including the garden had been kept clean and tidy whilst the builders had to use areas of the home and garden to access the building site. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A number of requirements and recommendations are made following the visit to the home including four (4) matters where evidence of completion was not available during this visit. The Statement of Purpose and Service User Guide need review and change to make sure that all the information needed to help prospective residents and their relatives make a decision about moving to the home is provided. The home needs to make sure that detailed information is collected about prospective residents needs when carrying out an assessment to make sure the home is able to meet their needs. Care planning, review and risk assessment arrangements require improvement to ensure that members of staff know how to provide the support and care necessary and residents can be confident their needs will be met in a way they prefer. Some work is needed to make sure that members of staff follow the home’s procedure for giving medication to confirm that residents can make decisions about what they need and can be confident that the home will make sure their medication needs are met. It is recommended that the home review what activities are provided at the home, how often and take into account the views of the people living at the home. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 7 Confirmation is needed to make sure the residents have a choice of food, a dietician has been consulted and that nutritional needs assessments have been completed by a person competent to do so. A number of policies and procedures need review to make sure that the practice of the home is supported by policy including safeguarding adults (adult protection), dealing with aggression and accidents and incidents. Recommendations are made for the home to review the Criminal Records Bureau (CRB) guidelines about the recording, storage and disposal of CRB checks and to provide a training schedule that makes clear what training had been completed, when and when refresher training was due including any specialist training. A requirement is made to ensure that the members of staff working at the home have received the training necessary to meet the assessed needs of the people using the service including mental health and first aid. A requirement has also been made for the home to risk assess the level of first aid training needed by the home to make sure the assessed needs of the residents can be met. 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 Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3 were assessed. Standard 6 does not apply. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was needed to make sure that any prospective resident and their relative/s had all the information they needed before making a decision to move to the home. Further work was needed to develop the assessment process used by the home to make sure that all the detail necessary to meet the residents’ needs was recorded. EVIDENCE: The manager told the commission that the Statement of Purpose and Service User Guide had been updated in 2006 as had been required following the inspection of the 31st May 2006 and that due to the changes taking place in the home further revisions were being made. The documents seen by the commission during the visit did not have all the information asked for in The National Minimum Standards for Older People and The Care Homes Regulations 2001. Some information about the staff skills and qualifications and the accommodation was printed off separately and shown to the commission during the visit. A requirement is made for the Statement of Purpose and Service User Guide to be updated to ensure that all the Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 10 information necessary to assist prospective residents and their relatives to make a decision about moving to the home is provided. A number of resident files were sampled. Assessments had been completed, signed and dated by the person completing the document. It would benefit the home to make sure that the name of the person completing the assessment was clear and their role in the home is documented. This would confirm that a person competent to do so carried out any assessment of a prospective resident on behalf of the home. The manager said that the system of assessment was introduced to the home during 2006 and that appropriate members of staff had been shown how to complete the document. Some of the information provided in the assessment document did not provide the detail necessary to support the care planning arrangements. For example one assessment said needs assistance with personal care but no details of how or why another entry said foot care was ‘good’ this comment did not confirm the information in the care plan. The home provides for people who need care due their age, a mental health need (mental disorder) or have dementia. The assessments viewed did not make clear which of these needs the resident had. A requirement is made to ensure that the home develops and improves the recording of more detailed information in the assessment document for all new residents. This will confirm that the home only admits residents whose needs they can meet. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvement is needed to ensure care planning arrangements provide clear and accurate information. The health needs of the people who use the service are met and residents are treated with respect and dignity. Some work was needed to make sure that members of staff followed the policy and procedure of the home when giving any medication or treatment. EVIDENCE: A number of care plans were sampled. The care plans viewed did not all correspond to the information provided in the assessment documents. For example one care plan said that a resident needed occasional assistance with cutting up some foods the assessment said the resident was independent when eating. The reviews completed said that there had been no change. Reviews had been carried out each month; the reviews were identified by a date and signature with ditto marks under each section of the care plan reviewed. The reviews did not show whether residents and or their relatives or representatives took part, where possible, in the review. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 12 A requirement is made for the home to review all the residents’ care plans to make sure that where a need has been identified a care plan is in place showing how the need must be met and to ensure that where changes in assessed need are identified these are recorded and documented as part of the review and the care plan revised. Where possible the resident or their relative or representative must be involved in the care planning and review process and their agreement documented. None of the care plans sampled had daily living risk assessments to show where a resident might be at risk, why and what action was needed to reduce risk to the resident. The care plans sampled included information about mobility problems and where assistance was needed with cutting up some foods none of these had been risk assessed. In one bedroom viewed a small bed rail had been placed under the bed for use by the resident, the manager and senior member of staff confirmed to the commission that a risk assessment had not been completed as the item had been supplied by a relative. A requirement is made that individual risk assessments based on the assessed needs of the people living at the home are carried out, documented, recorded and reviewed as necessary. The system in use by the home has a separate section for recording visits from health professionals, of the care plans sampled one had an entry confirming a doctors visits. The section of the files sampled used by the home for recording activities included information about chiropody and dental appointments. One relative spoken with during the visit confirmed that appointments with a dentist and chiropodist had been made. In discussion with a senior member of staff and the manager the commission confirmed the health needs of the people using the service were met. Observations made during the visit, information provided in the returned AQAA, some supervision records and discussion with four residents and two relatives confirmed that the home treated the people who use the service with respect and dignity. Following the inspection of the 31st May 2006 three requirements had been made. During this visit it was confirmed that each of the requirements had been met. A refrigerator had been provided to store some medication such as eye drops. The senior member of staff spoken with during this visit said that temperature recordings of the small fridge were not taken and where reliable temperatures were necessary a small box would be placed in the main fridge in the kitchen. Discussion with the manager and senior members of staff, a training record kept by the home and copies of training certificates viewed by the commission Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 13 confirmed that members of staff had received training in giving medication as required from the inspection of the 31st May 2006. The record book kept by the home to show what medicines had been returned to the pharmacist was looked at. As required during the inspection of the 31st May 2006 the pharmacist was now signing the book to confirm what medication had been returned. The commission sampled a number of medication records and found gaps in signatures and information showing where two residents had regularly refused the medication prescribed by the doctor and a risk assessment had not been completed. The gaps in signature related to the use of a cream, the senior member of staff spoken with said that the resident did receive the help needed and that members of staff were aware that they had to sign the use of a cream. A notice was on the wall in the office that confirmed this. Records had been made where the cream had not been applied and why one of which said the person was in bed. A requirement is made to ensure that the members of staff follow the policy and procedure of the home when giving any medication. Where residents had refused medication a record had been made of the refusal but not the reason. The home would benefit from making clear in the care plans where any person regularly refuses medication the reason why and to seek their signature to confirm their refusal. Where the doctor has prescribed medication that is no longer needed by the resident on a regular basis the home would benefit from recording this and discussing with the doctor and the resident whether the prescription required review. The home did not have any controlled medication at the time of the visit; the home did not have any storage options for controlled drugs if they were prescribed. It would benefit the home to have an appropriate cupboard for storing controlled medication. This would mean that if the doctor prescribed any controlled medication there would be no delay in being able to collect the prescription and making sure the resident could be given the medication needed. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some work was needed to confirm that the home took into account the views and abilities of the people using the service when providing activities and to make sure residents nutritional needs were being met and they had a choice of meal if preferred. The people who use the service were able to maintain family links. EVIDENCE: The care plans sampled showed some of the hobbies that residents liked to follow such as reading and knitting. One section of the care plan system showed what activities were provided in the home such as bingo, reminiscence and discussions. Only one of those sampled showed that a resident had taken part in the activities provided by the home. Other records showed visits from family members, needlework, knitting, reading newspapers and watching television. The Statement of Purpose said that one member of staff set aside one hour a day to provide activities for the residents. The senior member of staff told the commission member of staff was not on duty during this visit and no activity was being provided. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 15 The AQAA states that residents are encouraged to pursue their daily routine and that they are also encouraged to participate in activities provided on a daily basis based on ability and preference. The AQAA noted that providing activities for older people is a ‘learning curve’ and the home used feedback to grow and improve the service they provided. Two relatives spoken with during the visit said that they could visit at any time and were made welcome by the home. Two birthdays were being celebrated at the home during the visit and members of staff were observed singing happy birthday to one of the residents. A recommendation is made that a review of the activities provided take place to make sure that, all those residents who wish, have the opportunity to take part in an activity of their choice. The review to take into account the assessed needs of the residents and their views including whether they have a mental health need or dementia, how they might take part and how activities might be provided on a more consistent basis. One resident and the senior member of staff told the commission that there was no choice of meal; the resident said they get fed up with sandwiches sometimes. Supper was observed during the visit and sandwiches and tea had been provided. The menu was viewed and alternatives for those who did not like what was provided were not clear. The returned AQAA stated that residents were given a choice of meal and that referral to a dietician only if there were concerns and on a doctor’s recommendation. The senior member of staff on duty said that the cook who was not on duty during the visit chose the meals. The manager was not able to confirm to the commission the outcome of the referral made to a dietician and said this had been the responsibility of another member of staff. The requirement made from the inspection of 31st May 2006 had not been met. One care plan viewed showed a completed nutritional assessment, the record had not been signed or dated. A requirement is made that the home confirm in writing to the commission the outcome of the referral to a dietician. A further requirement is made for the home to review the care plans and ensure that where necessary a nutritional assessment had been completed, signed and dated by a person competent to do so and confirm in writing to the commission how meal choices are supported. This will make sure that the nutritional needs of all the residents are being met and confirm that a choice of meal is available if preferred. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints policy was in place and residents and their relatives could be confident that their views would be listened to and acted upon. Improvement was needed to make sure that the policies and procedures for safeguarding adults at the home supported practice. EVIDENCE: The home had several versions of a complaints procedure, one on the Statement of Purpose and two in the home’s policy and procedure file, none of the copies were the same. Timescales had not been provided and others had different names and addresses for the commission. The manager updated the complaints procedure during the visit to make sure that a timescale for response was given, the name of the commission was correct and added the new address for the commission. A copy was passed to the commission to confirm revision. The manager said that the home had not received any complaints since the last inspection and that any matter raised by a resident or relative was dealt with immediately in order that it did not result in a complaint. It might benefit the home to make a record of matters raised and the outcome in order to gain a view of how the home is running and use as part of their quality assurance audit outcomes. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 17 Four residents and two relatives spoken with during the inspection said they knew who to talk to if they were unhappy with the service none had made a complaint. As required following the inspection of the 31st May 2006 the members of staff had received training about adult protection (safeguarding) and certificates to confirm attendance were sampled. The home had a policy for safeguarding adults the procedure in place stated that the manager would investigate; this does not support the local authority multi-agency safeguarding guidelines. The manager showed the commission a written document setting out what to do and what not to do when an allegation is made, the information had been provided as part of the training received. A policy and procedure for dealing with aggression was in place, the policy said that members of staff were to push the panic button and that annual training would be provided. The manager confirmed that the home did not have a panic button. Please also see training matters. A requirement is made to ensure that the safeguarding policy and procedure and any related policy and procedure such as whistle blowing and dealing with aggression are revised to ensure they support the local authority guidelines, this will make sure that policy supports the practice of the home. No safeguarding allegations had been received or made by the home since the inspection of 31st May 2006. A policy and procedure for the use of restraint was in place. The manager confirmed that members of staff had not received training in restraint from an accredited trainer and that restraint is not used by the home. The manager immediately removed the policy. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained, comfortable and was clean and hygienic throughout. EVIDENCE: A tour of the home took place. The home was registered for fourteen (14) placements and were providing for twelve (12) and had provided a third shared bedroom to allow for internal transfer as part of the building work taking place. The manager said she expected the building work to be completed by September 2007 and she would then vary the registration to show more places were available. The manager told the commission that all the bedroom furniture provided by the home had recently been replaced and that the carpets and curtains will be replaced as the building work allows. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 19 All but one of the bedrooms was viewed and those seen had been personalised by the residents for example with photographs of their family and other personal items. The communal areas and garden were also seen and these areas were being kept in good order and as clear as possible while the building work continued. The parking area to the front of the home was affected by the building work as space was very limited and visitors were being asked to park elsewhere. No concerns were raised during the visit. A bin in the downstairs hall appeared to have a sticking lid and contained used disposable gloves it would benefit the home to make sure the bins provided were all in good order to reduce the risk of possible cross infection. The home was clean and hygienic. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The recruitment and qualifying training policy and practice of the home supports and promotes the needs of the people who use the service. Improvement is needed to make sure that the members of staff are trained and competent to do their job and can meet all the assessed needs of the residents. EVIDENCE: The senior member of staff on duty told the commission that three members of staff are always on duty during the day and two at night. The night-time was covered by one waking member of staff and one sleep-in. The rota for the week of the visit had not been fully completed, as cover was needed for those days when the senior member of staff would be on leave. The commission were informed that this was in hand and she was waiting for confirmation from care staff about their additional working days. The home had ten (10) members of staff employed including the cook and manager. Six (6) of the (8) care staff had a National Vocational Qualification (NVQ) four (4) at level 3 and two (2) at level 2. The manager provided a written record of the qualifications of the care staff to the commission during the visit. A number of staff personnel files were sampled. Some files seen showed that some members of staff had been working at the home for some time one Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 21 starting work in 1999 offering a stable and consistent base to the staffing available. One file seen showed that a verbal reference had been sought; a record of the discussion and the outcome had not been made. The manager said that they would make a record of the discussion and ensure a copy was available on the file. A tick list was provided in the front of some of the files seen to show what records or documents had been received or made by the home. The home would benefit from providing a checklist that set out what had been received, when, whether the information was satisfactory and for an appropriate member of staff to sign. This would assist the home in making the information easier to access and confirm that all the recruitment information required was in place. The home uses an on line umbrella organisation to carry out Criminal Records Bureau (CRB) checks, the umbrella organisation kept a record of completed checks including PoVA checks. A PoVA check ensures that any applicants are not on the list of people not suitable to work with vulnerable adults. Some application forms and photocopies of the original CRB documents were held on the staff files. A recommendation is made for the home to review the Criminal Records Bureau’s guidance regarding the storage, recording and disposal of CRB checks. The home had completed a training information document that set out what training had been received by members of staff. The document did not show what date the training had been completed; a member of staff told the commission that those ticked had been completed in 2007. On checking the information on the training document, talking to the manager and a senior member of staff it was confirmed that the home did not have a qualified first aid person working at the home. The manager’s qualification had ended in April 2007 and the manager told the commission that two other members of staff had received basic training in first aid. One certificate was seen showing a basic first aid course had been completed in 2004. During the visit the manager said she had booked herself onto a first aid qualifying course for July 2007 following the findings of the inspector. A requirement is made that the home review and risk assess the need for basic and/or qualified first aid training taking into account for example the assessed needs of the residents and the number of incidents and accidents at the home and to notify the commission in writing of the outcome. This will ensure that the home makes sure that an appropriate number of care staff are suitably trained in first aid. Some staff had received training in dementia awareness and none of the care staff had received training in mental health. The manager said that training in the Mental Health Act had been completed; this had not been confirmed in Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 22 their training schedule. The commission were told by the manager that one member of staff was doing a longer course on dementia. A requirement is made that the home review the training provided by the home including dementia and mental health to make sure all the training needed to meet the assessed needs of the people who use the service is provided to all members of staff including where required the manager. A recommendation is made that the home revise the training document to show what training is required by the home, when last provided and when a refresher is due including specialist training such as dementia and mental health and to keep the document up to date. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 and 38 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvement is necessary to make sure that the home promotes and protects the health, safety and welfare of the people using the service and takes into account wherever possible their views and wishes. EVIDENCE: The registered manager was also the owner of the home. The manager told the commission that she had completed the registered managers award and provided the commission with written confirmation that she had nineteen (19) years experience in the care sector. As noted earlier the managers qualified first aid certificate had lapsed and she had booked herself on a course to start in July 2007. Please see the Staffing section of this report. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 24 The AQAA was received on the 9th July 2007 and forwarded to the commission by email. Please see summary of this report for details. The manager said that the home had started a quality assurance audit with the people who use the service. A number of questionnaires were seen in resident’s files, not all had been completed. The senior member of staff spoken with said that not all of the residents would be able to complete the questionnaire, as they would not understand what they had been asked to do. The member of staff confirmed to the commission that a record stating that a resident could not complete a questionnaire had not been made. The requirement made during the inspection of the 31st May 2006 had not been met. A further requirement is made for the home to complete the quality assurance audit and include the views of relatives and stakeholders where possible and to record and document the outcomes and make them known to the residents and their relatives. The manager and senior member of staff told the commission that the home does not assist any resident with their finances. Where necessary the home will provide funds to cover costs such as hairdressing and invoice as part of the overall fee. The accident and incident reports were sampled. The records were held in the home’s accident book and none of those sampled indicated the need for notification to the commission. The requirement made on the 31st May 2006 had been met. A requirement is made to ensure that the accident and incident records are filed appropriately to maintain the confidentiality of the people who use the service. This was discussed with the senior member of staff during the visit. The AQAA had not been completed by the home by the time of the visit and the commission sought to sample the gas safety certificate and legionella testing outcome. The manager said these matters had been dealt with and that certificates were available to confirm. The manager was unable to find the documents during the visit and a requirement is made that the home confirms in writing to the commission that certificates are in place and the date completed. This will confirm that the requirement from the inspection of the 31st May 2006 had been met. A number of policies and procedures were viewed including admissions, confidentiality, continence and accident and incidents. It was found that over time the practice of the home had changed in a number of areas and the policies and procedures in place did not reflect the practice of the home. A requirement is made that the home review and revise policies and procedures as necessary and that practice supports policy, this will make sure that the members of staff working at the home are clear about what is expected of them and why. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 25 The commission saw evidence that some members of staff had received training in, for example, manual handling and fire safety and training certificates had been provided. Please see the Staffing section of this report. A discussion took place with the manager about the records and documents completed by the home and the need to make sure they are available, up to date, accurate and clear. The manager was aware of this and said that she would be taking action to make sure that these matters were dealt with. Matters raised during the visit including the care planning arrangements, staff training and the difference between policy and practice in some areas do not confirm that the home promotes and protects the welfare and well being of the people who use the service. Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4,5,6 Requirement The Statement of Purpose and the Service User Guide must be revised to make sure all the information required in the National Minimum Standards for Older People and The Care Homes Regulations 2001 are provided. This will make sure prospective residents and their relatives know what the home does or does not provide and what they can expect from the service. The home must further develop and improve the information gathered for assessment purposes to make sure adequate detail is provided including whether the new resident has a mental health need, dementia or other specific health need. This will confirm the home will only offer a placement to residents whose assessed needs they can meet. The care plans must be reviewed, where possible with the resident, their relative or representative, to make sure the information provided is up to DS0000013596.V345122.R01.S.doc Timescale for action 28/09/07 2. OP3 14 06/08/07 3. OP7 15 28/09/07 Cherry Lodge Rest Home Version 5.2 Page 28 4. OP9 13(2) 5. OP7 13(4) 6. OP15 16(2)(i) OP8 date and accurate and has adequate detail to make sure members of staff are aware of the residents needs and how they must be met. The reviews must make clear what, when and why any changes to the residents assessed needs have taken place. Members of staff must follow the 27/07/07 policy and procedure of the home for recording medication including the use of creams. This will confirm that residents have been given and/or received the medication or treatment prescribed by the doctor. Daily living risk assessment 31/08/07 including mobility and the use of any bed rails must be carried out and reviewed regularly taking into account the assessed needs of the people who use the service to make sure that any support, care or activity carried out considers the well being and safety of the resident. 10/08/07 Written confirmation of the outcomes from the referral by the home to the dietician must be sent to the commission including action taken to meet any recommendations made. The timescale from the inspection of the 31st May 2006 has not been met. Written confirmation that a choice a meal is available and that nutritional assessments have been completed on all residents as necessary by a person competent to do so must be sent to the commission. The policies and procedures of the home including adult protection, whistle blowing, DS0000013596.V345122.R01.S.doc 7. OP18 13(6) 28/09/07 Cherry Lodge Rest Home Version 5.2 Page 29 OP38 8. OP30 18(1) 9. OP30 OP31 18(1) 10. OP31 OP37 12(4) 11. OP33 OP31 24(1)(a) (b) dealing with aggression and accidents and incidents must be reviewed and revised taking into account the practice of the home, the assessed needs of the residents and where necessary other agencies guidelines, for example the local authority multi-agency guidelines for safeguarding adults. A risk assessment must be carried out with regard to first aid training taking into account for example the assessed needs of the residents and the type and number of incidents and accidents at the home in order that the home can decide what level of training is required by members of staff and make the necessary arrangements to meet the outcome of the risk assessment. A review of the training provided by the home must be carried out and action taken to make sure that all the members of staff receive the training they need to meet the assessed needs of the people who use the service user including specialist training such as mental health. Any record held by the home including the accident and incident records must be filed appropriately to confirm the confidentiality and privacy of residents. The registered person must carry out an annual survey of service users, family, friends, stakeholders and produce a report for information to ensure the home is run in the best interests of service users. A copy to be forwarded to the commission. Timescale from the DS0000013596.V345122.R01.S.doc 10/08/07 10/08/07 10/08/07 31/08/07 Cherry Lodge Rest Home Version 5.2 Page 30 12. OP38 OP31 12(1)(a) inspection of 31st May 2006 not met. 10/08/07 The registered person must confirm in writing the outcome of the legionella bacteria test to ensure action had been taken to promote the safety of staff and service users. Timescale from the inspection of the 31st May 2006 not met. The registered person must confirm in writing that a gas safety certificate has been provided for the home to confirm that action had been taken to safeguard the welfare of service users. Timescale from the inspection of the 31st May 2006 not met. 13. OP38 OP31 12(1)(a) 10/08/07 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 OP12 Good Practice Recommendations It is recommended that the activities provided by the home be reviewed taking into account the views of the people who use the service. This will assist the home to make sure regular activities as preferred by the residents are available. It is recommended that the home review the Criminal Records Bureau (CRB) guidance with reference to the storage, recording and disposal of CRB checks. It is recommended that the home complete a training information schedule to show what training had been completed including specialist training, the date completed and when refresher training is due. This will assist the home to make sure that staff training is kept up to date. 2. 3. OP29 OP30 Cherry Lodge Rest Home DS0000013596.V345122.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU 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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