Inspection on 31/05/06 for Cherry Lodge Rest Home

This inspection was carried out on 31st May 2006.

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

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

Other inspections for this house

Cherry Lodge Rest Home 29/01/08

Cherry Lodge Rest Home 29/10/07

Cherry Lodge Rest Home 02/07/07

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 Deavanand Ramdas Unannounced Inspection 31st May 2006 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.V297926.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.V297926.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.V297926.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) 29th September 2005 2. 3. Date of last inspection Brief Description of the Service: Cherry Lodge is registered with the CSCI (commission for social care inspection) to provide accommodation and care for fourteen older people. 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 which is well maintained, private and secure with wheelchair access. Private parking is available. The registered manager is Cherie Callender. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes key inspection which was unannounced and a tour of the premises took place, staff and service users were spoken to, and documents and records were examined. The inspector noted some service users had a memory impairment and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff and service users for their contribution to the inspection. What the service does well: What has improved since the last inspection? The provider has made significant investment to make the home comfortable and safe for service users with the installation of double glazing, new gas boilers, furniture and fittings and painting and decorating of service users bedrooms. During discussions a service user stated ‘‘I have been to lots of places, nowhere like this one. It is always very nice and clean’’. The provider has purchased and introduced a standardised care planning system based on good practice to ensure service users individual needs are assessed and recorded and the home has met the previous requirements and recommendations which have resulted in improvements in the areas of medications, risk assessments, records and recruitment and vetting practices to protect service users from harm and abuse. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service guide needs strengthening to ensure prospective service users and their relatives have up to date information on which to make decisions about admission to the home. The arrangements for the assessment of needs are adequate ensuring service users’ needs are assessed before admission to the home. EVIDENCE: The home has a statement of purpose and service user guide which is written in plain English, nicely presented and copies are available to service users for information. A requirement has been made for the statement of purpose to be updated with the relevant qualifications of the manager and staff working at the home for information and the service user guide is amended to reflect the CSCI (commission for social care inspection) as the regulatory body of the home. The manager stated service users are admitted to the home on the basis of an assessment of needs and the home had an assessment and admissions policy. The inspector sampled records and noted the home had a Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 9 dependency profile which is used to assess service users’ needs and covered the areas of personal care, social support and healthcare needs. The manager stated the home does not offer intermediate care and this standard was not assessed. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning at the home is satisfactory ensuring service users have individual care plans which reflect their individual needs. The systems for accessing healthcare are adequate ensuring service users healthcare needs are assessed and met. The arrangements for privacy and dignity are adequate ensuring service users privacy is upheld. The management of medications at the home needs strengthening to promote the health of service users. EVIDENCE: The manager stated service users have care plans which are drawn up following an assessment of needs and the inspector noted the home had invested in a standex care planning system which sets out in details actions to be taken with regards to personal, social and health care needs. The manager stated service users have named key workers and care plans are regularly reviewed, updated and changed to reflect service users changing needs. The inspector sampled care plans which were reviewed and updated in May 2006 Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 11 and dated and signed by key workers. During discussions the deputy manager stated ‘‘the priority is the service users and they are well taken care of’’ and a service user commented ‘‘the care is very good, I get well looked after’’. The manager stated service users have access to healthcare professionals to meet their needs and the inspector noted service users are registered with a local GP and the home have input from the district nurse and a specialist nurse in diabetes to meet the needs of service users. The deputy manager stated the home had a policy on medications and the inspector noted the home had a service level agreement with a local chemist and an audit was carried out by a pharmacist on the 24/4/06 and appropriate management action taken. Medication record sheets had a recent photograph of service users, were dated and signed by staff and a list of staff specimen signatures was available for information. The inspector noted shortfalls in the management of medications and a requirement has been made for the home to provide a small refrigerator for the storage of medications, staff to have accredited training in medications and medications returned to the pharmacy is signed and dated by pharmacy staff to promote the safe handling of medications. The manager stated the home had a policy on privacy and dignity and the inspector noted the home had information on the GSCC (general social care council) code of conduct for care staff. Observations confirmed staff addressed service users by their preferred names and the manager knocking on doors before entering service users’ bedrooms. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for activities are satisfactory ensuring service users social and cultural interests are catered for by the home. The systems for family contact are adequate ensuring service users maintain links with family and friends as they would wish. Opportunities for exercising choice are satisfactory ensuring service users are helped to exercise choice over their lives. Meals at the home are adequate and offer variety and choice. However, menu plans need to be reviewed by a dietician to ensure they meet the nutritional needs of service users to promote health. EVIDENCE: The manager stated the home had a policy on social contact and activities and the inspector noted service users have the opportunity to exercise choice in relation to leisure, social activities and cultural interests recorded in service users daily notes and in the homes activities diary. It is recorded service users participated in board games, movement to music and ‘sing along’. During discussions a service user from an ethnic minority stated ‘‘I join in the singing and dancing and everyone has a laugh. There is no prejudice’’ and remarked ‘‘I am a Roman Catholic and go to church every Sunday which makes me very happy’’. The inspector noted the home provided information on activities in a Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 13 format which is understandable and used large pictures to reflect daily activities in the home. A review of records indicated service users had contact with family and friends and the home had a flexible visitor’s policy to promote links with relatives. The manager stated service user have opportunities to exercise choice and during discussions a care staff stated ‘‘service users exercise choice in clothing and meals’’ and a service user remarked she had ‘‘a small fridge in her bedroom to store orange juice’’ for personal use and enjoyment. The manager stated the home had written menu plans and the cook commented service users participated in planning the menu. Observation confirmed service users had roast chicken, boiled potatoes, cabbage and carrots for lunch and dessert was semolina pudding or fresh fruits. Mealtime was relaxed and unhurried and meals were nicely presented. During discussions a service user stated ‘‘food is very good, it is enough for me’’. A review of menu plans indicated meals were varied and offered variety and choice and following discussions with the cook a requirement has been made for the homes menu to be assessed by a dietician to ensure it is adequate to meet the nutritional needs of service users to promote good health. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints process is satisfactory with complaints information available to staff, service users and relatives. The arrangements for protection needs strengthening to ensure staff have access to the local authority training on safeguarding adults to protect service users from harm and abuse. EVIDENCE: The manager stated the home had a complaints policy which is available in the policies and procedures file and the inspector noted complaints information in the service users guide. The manager stated the home had a complaints folder which was sampled and no complaints were recorded. During discussions a staff stated she was ‘‘aware of the complaints procedure’’ and a service user remarked ‘‘I am happy and have no reason to complain’’. The home had a policy on safeguarding adults and a recognition and prevention of abuse leaflet for information. The manager attended the local authority (surrey county council) training on safeguarding adults and staff working at the home have in-house training in safeguarding adults by the manager. Following discussions, a requirement has been made for the manager to review training in safeguarding adults to ensure staff have access to the local authority training to protect service users from harm or abuse. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24&26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the premises are adequate ensuring service users live in a safe and comfortable environment. Communal facilities are satisfactory ensuring service users have access to shared sitting, recreational and dining space. Bedrooms are satisfactory and promote the privacy and comfort of service users. The arrangements for hygiene are adequate ensuring the home is clean and hygienic for service users. EVIDENCE: The premises is safe and well maintained and the garden is tidy, attractive and accessible to service users. During discussions a service user stated ‘‘she enjoyed going for walks in the garden’’ and the inspector noted the provider had made significant investment to improve the quality of the environment for service users by installing new gas boilers, assisted baths, double glazing and Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 16 the home have decorated a number of bedrooms to make it nice and attractive for service users. The communal areas were nicely decorated with adequate furniture and fittings and observations confirmed the home had televisions, CD players, a selection of video’s and magazines for the enjoyment of service users. The bedrooms were well presented, personalised and shared bedrooms had screens to promote the privacy of service users. The inspector noted bedrooms had plants, ornaments, pictures, paintings and one service user who liked animals had a picture of the family cats in her bedroom for her enjoyment and pleasure. On the day of the inspection the home was clean and free from mal odour and the manager stated the home had policies and procedures for the control of infection and staff had infection control training reflected in training records. Observations confirmed the home had a laundry room with sluicing facility and staff practiced infection control measures by washing their hands regularly to prevent the spread of infection in the home. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are adequate ensuring there are sufficient number of staff to meet the needs of service users. NVQ (national vocational qualification) needs strengthening to ensure service users are in safe hands at all times. The systems for recruitment are satisfactory however recruitment files must have an up to date photograph of employees to protect service users from harm or abuse. Induction training is satisfactory ensuring staff are trained and competent to do their jobs. EVIDENCE: On the day of the inspection the home was adequately staffed and the registered manager, deputy manager, three support workers and a cook were on duty which was reflected on the duty roster. During discussions a staff stated ‘‘staffing levels at the home are good’’ and the manager commented the home had one vacancy for a support worker. The home has two staff working towards the NVQ (national vocational qualification) Level 3, and four staff have completed the Level 2 award. The home has a fulltime establishment of eleven employees and following discussions with the manager a requirement has been made for an action plan to be sent to the CSCI (commission for social care inspection) outlining how the home would meet the NVQ training targets to ensure service users are in safe hands at all times. The manager stated the home had a policy on Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 18 recruitment and the inspector sampled recruitment files which had completed application forms, references, statement of terms and conditions and CRB (criminal records disclosure) information was kept electronically. The inspector noted recruitment files did not have an up to date photograph of employees and action has been required in respect of this matter to protect service users from harm or abuse. The manager stated the home had an induction workbook, an induction checklist and staff working at the home have induction training which covered the values and principles of care, policies and procedures, health and safety and was dated and signed by the supervisor and employee. During discussions the deputy manager stated ‘‘I have supervision and support from the manager’’. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the day to day management of the home are adequate ensuring service users live in a home which is run and managed by a person fit to be in charge of the home. The systems for quality assurance need strengthening to ensure the home is run in the best interests of service users. Policies and procedures for managing service users’ money are satisfactory ensuring the financial interests of service users are safeguarded. The arrangements for health and safety need improving to safeguard the welfare of staff and service users. EVIDENCE: The home has a registered manager who provides management stability and is working towards the RMA (registered managers award). The inspector noted Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 20 there are clear lines of accountability which is reflected in the organisational chart in the homes statement of purpose and during discussions staff stated ‘‘the manager was approachable, supportive and flexible’’. The manager stated the home had a policy on quality assurance and the home had discussions with staff, service users and families to obtain feedback about the home. The inspector noted the quality assurance measures in the home were informal and unstructured and following discussions with the manager a requirement has been made for the home to conduct a survey of service users, family, friends, stakeholders including the GP and produce a report of the results for information to ensure the home is run in the best interests of service users. The manager stated the home had a policy on service users money and property which was in the policies and procedures file and service users at the home have appointees. The inspector noted the home invoiced appointees for any incidental spending and had no control of service users’ money to safeguard their financial interests. The home has a health and safety policy and staff have training in health and safety, first aid, food hygiene, infection control and moving and handling and a fire risk assessment was carried out on the 30/3/05 and appropriate action taken. The home had a policy on COSHH (control of substances hazardous to health) and observations confirmed COSHH products were stored in a locked cupboard and the home had data sheets to promote the safety of service users. Following discussions with the manager a requirement has been made for the home to carry out a legionella test to promote the health and safety of service users, a copy of the gas safety certificate sent to the CSCI (commission for social inspection) to safeguard the welfare of service users, and notifications to the CSCI must be in a standard format to ensure clarity and consistency of information to safeguard the interests of service users. Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 21 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation 6 Requirement The registered person must ensure the statement of purpose is updated and the service user guide is amended to ensure prospective service users have up to date information to make an informed choice about admission to the home. The registered person must provide a small refrigerator for the storage of creams, eye drops and elixir to promote health. The registered person must ensure staff have training in medications which is accredited to promote health. The registered person must ensure the record of medication returned to the pharmacy has the signature of a pharmacy staff to prevent mishandling of medications. The registered person must ensure menu plans at the home have dietician input to ensure it is adequate to meet the nutritional needs of service users. The registered person must ensure staff working at the home DS0000013596.V297926.R01.S.doc Timescale for action 01/07/06 2. 13(2) 15/06/06 3. 13(2) 01/08/06 4. 13(2) 01/06/06 5 16(2)(i) 01/07/06 6 13(6) 01/08/06 Cherry Lodge Rest Home Version 5.2 Page 23 7 18(1)(a) 8 7 Schedule 2 9 24(1)(a) (b) 10 12(1)(a) 11 12(1)(a) 12 37 have the local authority (surrey county council) training in safeguarding adults to protect service users from harm or abuse. The registered person must draw up an action plan outlining how the home would meet NVQ (national vocational qualification) training targets for staff to ensure service users are in safe hands at all times. The registered person must ensure recruitment files have an up to date photograph of employees to safeguard the welfare of service users. 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. The registered person must ensure the home has a legionella bacteria test to promote the safety of staff and service users. The registered person must ensure a copy of the gas safety certificate is sent to the CSCI (commission for social care inspection) to safeguard the welfare of service users. The registered person must ensure notifications to the CSCI (commission for social care inspection) are in a standard format to ensure consistency and clarity of information to safeguard the interests of service users. 01/07/06 01/07/06 01/10/06 20/06/06 05/06/06 01/06/06 Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations No recommendations were made at this inspection Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cherry Lodge Rest Home DS0000013596.V297926.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!