CARE HOMES FOR OLDER PEOPLE
Cherry Lodge Rest Home Cherry Lodge 75 Whyteleafe Road Caterham Surrey CR3 5EJ Lead Inspector
Lisa Johnson Announced 08 July 2005 10:00 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 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 H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 Telephone number Fax number Email 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 Michael George Callender Mrs Cherie Margaret Callender 75 Whyteleafe Road, Caterham, Surrey, CR3 5EJ Mrs Cherie Margaret Callender Care Home (CRH) 13 Category(ies) of Old age, not falling within any other category registration, with number (OP) 13 of places Dementia - over 65 years of age (DE(E)) 6 Physical disability (PD) 1 Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 6 Physical disability - over 65 years of age (PD(E)) 1 Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 who may be in the age range 60 to 65 years 2 Of the older people accommodated up to 6 may be in the category MD(E) and/or DE(E). 3 Of the older people accommodated one person may have a physical disability PD(E) Date of last inspection 07 September 2004 Brief Description of the Service: Cherry lodge is a large detached property situated in a residential road in Caterham. The home has an attractive garden to the rear of the property and car parking facilities at the front of the home. The home is registered for fourteen service users . Accommodation consists of`two floors with a stair lift for easier access to the upstairs rooms. Ten of the bedrooms are for single occupancy and there are two double bedrooms. Some of the bedrooms have en-suite facilities. A disabled bathroom is available downstairs and another new bathroom has been installed recently. There is a large lounge and separate dining room. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first inspection carried out in 2005/2006. Two inspectors carried out the announced inspection over five and half hours. The main focus of the inspection was to review any requirements made at the last inspection. A tour of the premises took place and care plans, policies and procedures and other required documents were sampled. The inspectors spoke to some of the residents who live in the home and spoke to the Registered Manager and one member of staff. The inspector would like to thank the residents and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: What has improved since the last inspection?
A requirement was made at the last inspection that a staff list be made available for staff who are able to administer medication and this is now completed. The home was very clean at this inspection and no offensive odours were apparent. The staff have received infection control training. The home had made an application that has been approved to increase the number
Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 6 of service users from thirteen to fourteen as the home has now gained an extra bedroom. A recommendation was made at the last inspection that information should be made available in relation to the control of harmful substances and this has received action. What they could do better:
At the last inspection a requirement was made that staff must receive adequate supervision and that records are maintained. This is still outstanding and a further requirement has been made that all staff should receive formal supervision at least six times a year to ensure that staff are practicing effectively and that training and development is identified to ensure that staff are carrying out their job competently. A previous requirement was made at the last inspection that risk assessments are implemented for five service users who have had accidents. This is still outstanding especially in relation to service users who are at increased risk of falls and this has been made an immediate requirement. During the inspection it was noted that the Commission for Social Care Inspection has not received any notification in respect of service users sustaining injuries due to falls. A further immediate requirement has been made that moving and handling assessments be undertaken for all residents to ensure the health, safety and welfare of service users and staff. A requirement has been made that care plans are reviewed and updated and s based on the outcome of a comprehensive assessment to ensure that all care plans are accurate and needs are being met. Care plans should be signed and dated. The medication administration records were sampled and some gaps were observed in non- administration of medication. A requirement has been made that an audit trail be implemented and where necessary service users medication reviewed. A recommendation has been made that if any medication is to be transcribed on to medication administration records two staff must be present to ensure the safety and welfare of service users. A requirement has been made that the complaint procedure for the home is amended to state that the Commission for Social Care Inspection can be contacted at any stage of a complaint if a complainant wishes to do so. The home has a Protection of Vulnerable Adult policy but needs to obtain an updated version of the local authority Protection of Vulnerable Adult procedure. This will ensure the safety and welfare of service users is promoted and protected. Staff files were sampled and evidence of police checks was not available. An immediate requirement was made that police checks must be carried out to ensure the safety and protection of service users.
Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 7 Dried food in the storeroom was found in opened packets and should be stored in sealed containers to meet food hygiene regulations. 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 H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 , 2, 3, 4 & 5. The home provides adequate information to enable prospective service users decide whether they wish to live there. Assessments are completed prior to admission. Trial visits are accommodated and contracts are in place. EVIDENCE: The home has a comprehensive statement of purpose that was professionally presented and clearly describes the services and facilities it is able to offer. A service user guide is in place and was observed to be maintained in service users bedrooms. It was evident that pre- admission assessments are completed prior to admission and trial visits are available which are flexible to accommodate the individual wishes of service users. Each resident is issued with an individual contract in the form of statement of terms and conditions. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 10 Care plans need to be implemented based on comprehensive assessments to ensure that health, personal and social care needs are being met. Appropriate risk assessments should be carried out so that appropriate interventions are in place for service users who are at risk of falls. The home needs to ensure that the homes policies and procedures for dealing with medications is adhered to so as to protect service users. Service users are treated with dignity and respect. EVIDENCE: Six care plans were sampled and evidence was seen that service users or representatives did not sign some care plans. No evidence was available that care plans were generated from comprehensive needs assessments. One service user was found to have a history of falls and no risk assessment had been implemented or interventions documented in care plans. Accident records were sampled and it was evident that a service user had suffered a number of falls and the home had failed to notify the Commission for Social Care Inspection. An immediate requirement has been made in this area. Requirements have been made that care plans be reviewed and set out in detail the action which needs to be taken to ensure that all aspects of the personal, health and social needs of service users, are met. The care plans
Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 11 must be based on assessment and include a risk assessment to identify appropriate interventions to reduce the risk of further falls. Medication cards were sampled and some were found to have some gaps in non- administration and in particular one service user was found not to have received his night medication on a regular basis. The staff member present stated that the service user was asleep, but no explanation was recorded. A requirement has been made that an audit trail be implemented and that medication reviews need to take place. Two recommendations were made that any transcribing of medication onto the medication administration record this should be completed by two members of staff and a photograph should be made available on individuals records. Service users were treated with dignity and respect. Staff were observed to knock on service users doors before entering and speaking to service users in a respectful manner. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 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 standard(s) 12 & 13 Service users were able to maintain contact with family and friends. Service users were offered a well-balanced, choice of meals. EVIDENCE: Service users confirmed that they maintain contact with family and friends and that there are no restrictions. Service users are able to see their relatives in private. A varied menu was available and the homes cook and home manager implement menus that are based on the individual likes and dislikes. At the time of the inspection the lunchtime meal was observed to be of a good standard and was nutritious. There was a relaxed and unhurried atmosphere in the dining room and service users were observed to be enjoying their meal. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 & 18 The home is able to demonstrate that there is an adequate complaints policy in place. Policies and procedures were in place to ensure that residents are protected from abuse. Some minor items were identified for action. EVIDENCE: A complaints policy is in place and maintained in the Statement of Purpose and service user guide. One matter was recently referred under the local authority Protection of Vulnerable Adults procedure and has now been resolved. A requirement has been made that the homes complaint procedure is amended to state that the Commission for Social Care Inspection can be contacted at any stage of a complaint if the complainant wishes to do so. The home has an Adult Protection policy, but needs to obtain an updated version of the local authority Protection of Vulnerable Adult policy. This will ensure that information is available to protect the safety and welfare of service users will be promoted and protected from abuse. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21, 23, 24, 25 & 26. The home is able to demonstrate that it provides a homely, well maintained, clean and safe environment for service users to live in. Bedrooms were well furnished and service users had their own possessions around them. EVIDENCE: The home is decorated to a high standard and is well furnished. There is ample communal space with a large sitting room and separate dining room. Since the last inspection a new accessible bathroom has been installed. The hall, landing, lounge, dining room and bedrooms have been redecorated. A new sluice room, staff office and a new toilet have been installed. Bedrooms were of a good standard and were decorated with individual’s belongings. There is an accessible garden and a new patio has been installed which is complemented by an awning. The home was found to be clean and hygienic with no pervading odours. Evidence was seen that that fire equipment checks take place and fire alarm tests take place weekly. The fire officer has made a visit to the home in March 2005, which also included fire training for staff. Fire drills are updated.
Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 15 Maintenance records were available for gas and electrical services and emergency call systems have been serviced. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The staffing levels were adequate to meet the needs of the service users. Staff are supported to undertake training and development to ensure that they are competent to carry out their job. The home needs to improve its recruitment procedure to ensure the safety of service users is protected. EVIDENCE: On the day of the inspection there were three staff on duty plus a cook. The duty rota was sampled and staffing levels range from two to four staff being on duty during the day plus the registered manager provides cover. Evidence was seen that staff training has been completed and updated including fire training, food hygiene, first aid risk assessment and moving and handling. Four staff have obtained National Vocational Qualifications. A recommendation was made that an up to date training schedule is put in place. Two staff personnel files were sampled and found to contain job descriptions and other required documents were in place. The manager stated that police checks were undertaken, but no evidence was available to confirm this. A requirement has been made that police checks must be completed for all staff to protect the safety and welfare of service users. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 36, 37 & 38. Adequate record keeping is maintained. Staff should receive formal supervision to ensure their practice and development needs are met to ensure the health and welfare of service users. The manager must ensure that food is stored appropriately and food hygiene regulations are adhered to. EVIDENCE: The manager is completing the Registered Managers Award and is a qualified assessor for National Vocational Qualifications. The manager has many years experience working with older people. A range of policies and procedures were in place, which included control of harmful substances, fire, accident reporting, first aid, continence promotion and infection control. Adequate record keeping was maintained, records were kept secure and a confidentiality policy was in place. No evidence was available that moving and handling assessments have been completed and this has been made an immediate requirement to protect the health and welfare of service users and staff.
Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 18 Evidence was seen that temperatures were recorded in the kitchen. However opened packets of dried foods were found in the storeroom and an immediate requirement was made that these are stored in sealed containers to meet food hygiene regulations. Some progress has been made in ensuring that staff have supervision. However this has been made a further requirement. The manager should ensure that all staff receive formal supervision at least six times a year. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 3 3 3 x 2 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 3 x x x x 2 3 2 Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 15 (1) (a) (b) (c) (d) Requirement All service users care plans must be reviewed, updated, and based on a comprehensive assessment to ensure that service users personal and health needs are met. A risk assessment must be completed for all service users who are at risk of falls and appropriate interventions are put in place. ( Timescale of 21/09/04 not met) The registered person must make arrangements to provide a safe system for moving and handling all service users. The registered person must implement an audit trail to monitor all gaps in records on medication administration records. There must be no gaps on medication records following medication administration. Where medication was not given the appropriate code must be entered on the medication administration recordsheet. The registered person must obtain the updated version of the local authority Protection of Vulnerable Adult Policy to ensure Timescale for action 1 month 8/8/05 2. 8 13 (4) (b) (c) immediate 8/7/05 3. 8 & 38 13 ( 5 ) immediate 8/7/05 1 month 7/8/05 4. 9 13 (2) 5. 18 13 (6) 1month 7/8/05 Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 21 6. 29 17 (2) schedule 4 18 ( 2) 7. 38 8. 38 16 (2) (j) 9. 38 37 (1) 10. 16 22 11. 9 13(2) that the safety and welfare of service users is promoted and protected. The registered must ensure that police checks are maintained and to be available on all staff filesto protect the welfare of service users. All staff must recieve formal supervision at least every 6 weeks ( Timescale 31/09/04 not met) All opened packets of food must be stored in sealed containers to adhere to food hygeine regulations. The registered manager must inform the Commission for Social Care inspection immediately of any serious accident sustained by a service user. The complaint policy must be amended to state that the Commission for Social Care can be contacted at any stage of a complaint should the complainent wish to do so. Service users medication must be reguarly reviewed with the General Practitioner. 1 month 8/8/05 2 months 8/9/05 immediate 8/7/05 immediate 8/7/05 1 month 8/8/05 1 month 8/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 36 9 9 Good Practice Recommendations The registered manager should consider updating the staff training schedule for maintaining up to date records for all staff training. The registered manager should consider making a photograph available on each service users medication administration record. The registered should consider two staff being available to witness any medication that is transcribed on to the
H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 22 Cherry Lodge Rest Home medication administration record. Cherry Lodge Rest Home H58 S13596 Cherry Lodge V221282 080705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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
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