Inspection on 24/01/07 for Cherry, Rowan and Aspen Villas Care Home

This inspection was carried out on 24th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherry, Rowan and Aspen Villas... 28/02/08

Cherry, Rowan and Aspen Villas... 16/11/05

Cherry, Rowan and Aspen Villas... 29/06/05

Cherry, Rowan and Aspen Villas... 02/03/05

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

CARE HOME ADULTS 18-65 Cherry And Rowan Villas Care Home Oakfield Lane Warsop Nottinghamshire NG20 0JE Lead Inspector Mr Doug Tunmore Key Unannounced Inspection 24th January 2007 9:30 Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry And Rowan Villas Care Home Address Oakfield Lane Warsop Nottinghamshire NG20 0JE 01623 844 064 01623 844 034 cherryvilla@btconnect.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) Oaklands Residential Home Mrs Brenda Bird Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named person may be over the age of 65 Sevice users shall be within category LD Date of last inspection 16th November 2005 Brief Description of the Service: Cherry and Rowan Villas is a care home providing personal care and accommodation for 13 younger adults who have and learning difficulties. The home provides 11 long term beds and 2 respite beds and has dedicated beds for this purpose. The home is owned by Oaklands (formally known as Warsop and District Mentally Handicapped Association), which is a registered charity. The home is located in a residential area of Warsop and is close to shops, pubs, the post office and other amenities. The home was opened in 1986 and consists of a 2 purpose built bungalows with a large community centre on the same grounds.11 of the homes bedrooms are single, and 3 of the bedrooms have en-suite facilities. The home has extensive gardens that are well maintained and easily accessible. There is ample car parking available. The homes current charges range from £389.00 to £439. 00. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by the Commission for Social Care Inspection (commission) including the homes previous inspection reports, their service history, the homes pre-inspection questionnaire and residents questionnaires sent to the home by the commission prior to this inspection. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The inspector spoke with two of the residents one of whom one was being case tracked and joined two residents for lunch. The inspector also spent time with the manager, deputy manager and one member of staff. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The manager stated that the requirement made at the last inspection had been addressed by the provider. She also commented that successful fund raising has resulted in more outings and activities for residents in the coming year. All training is also up to date for all staff. A new Argo (specialised bath) has been installed, as well as a new walk in shower and the kitchen has been refitted. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 6 The provider has purchased a new mini bus with hydraulic ramp as well as a new car to take residents for appointments and outings. 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. The summary of this inspection report can be made available in other formats on request. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home does not have a comprehensive care needs admission assessment, which helps to ensure that a residents needs would be met. The provider does not undertake a care needs assessment prior to admission of a resident. All residents have a contract and terms of conditions. EVIDENCE: A review of all information available prior to this inspection and evidence seen at a previous inspection carried out in June 06 demonstrates that the home would admit residents only after a care needs assessment has been undertaken by health care agencies, social workers and psychiatrists. However, the provider does not carryout a pre-admission assessment of residents care needs prior to admission. This would help to ensure that the home could meet the needs of a resident and that the residents expressed hopes and aspirations would also be met. Residents files did not evidence that the provider has sent a letter to prospective residents confirming that the home can meet their needs. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 9 Prospective residents are given the homes pre-placement agreement to sign and they also receive a service users guide, which is also available in pictorial form. Information received from the home also showed that residents files contained the homes charter of rights for residents and terms and conditions of residency for both long stay and respite care residents. The commission has received fourteen questionnaires (surveys) sent to the home prior to this inspection. Residents completed the surveys with support from carers in some instances. The surveys showed that all residents wanted to move to this home and that they had enough information about the home prior to admission. Comments made in one survey was that ‘my brother said I would like it here. I visited Oakland’s before (admission) and knew it would be all right’. One resident seen stated that ‘a social worker brought me to have a look around and then I had a tea visit. I felt that I could live here. This was for respite and then I came full time and it was the right place for me’. The manager stated that she was unaware that she had to undertake preadmission care needs assessments or write confirming a place for residents. This she said would be undertaken in the future. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to be proactive and encourage residents to be involved in their care plans and risk assessments. Annual reviews take place for all residents which address their overall care needs. EVIDENCE: A review of all information available prior to this inspection and previous key inspections carried out in June 06 at this home evidenced that residents had an individual care plan. This inspection found that the care plans of two residents who were being case tracked, one of which was a respite care resident, had been reviewed on a regular basis by a multi-disciplinary team and reflected the changing needs of the residents. Records seen evidenced that neither residents nor their representatives had been involved with their care plans, signing them to confirm that they agreed that the plan of care was mutually agreed. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 11 The home does not have a care plan/review questionnaire, which explores with residents or their representatives their care plans and its purpose. This practice would show that residents and their families are actively involved with planning their care and understanding what their individual care plan is for. Residents files seen showed that relatives are contacted regarding issues affecting their sons or daughters. Previous inspections also found that ‘residents are able to make decisions according to their ability’. Residents surveys showed that all but one felt that they could make decisions about what they do each day including evenings and weekends. Previous reports also recorded that residents are carefully monitored as to what they are able to do according to their ability and that responsible risks being taken were identified, including taking part in activities out of the home. Residents risk assessments were seen and found not to have been signed by residents or their representatives agreeing to the risk identified and/or the change in their care plan and how this might affect their daily living. A resident commented that she had a care plan and also had plenty of reviews with her social worker, community nurse and psychiatrist. The resident also said that she had not signed any of these documents. She further commented that ‘carers are very good, even when I was very ill they never got angry and helped me’. Comments from residents surveys were that ‘I like it here its near my mum so I can go and visit her’. ‘I am happy at Oakland’s and would say if I wasn’t’. Other comments from residents surveys showed all felt that carers listen and act on what they say. Evidence was received from the home which showed that house meetings are held in which residents are empowered to raise any issues and discuss the running of the home. This inspection showed that the last house meeting was undertaken on the 24/12/06 and issues discussed related to looking forward to Christmas, raising funds for holidays and having a shop to sell things. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have a busy and varied lifestyle, with opportunities to engage in a range of leisure and cultural activities within the home and community. Meals are varied and residents plan the menu on a weekly basis. EVIDENCE: Previous inspection have evidenced that the home has close links with a local day centre where a number of residents attend. Residents also have opportunities to follow a variety of interests at the day centre which includes horticulture, farming and independent living skills. The provider has arranged for residents to attend literacy and numeracy courses and two 2 residents are undertaking distance learning in basic food hygiene. Other residents had expressed an interest in obtaining work experience in which they are to be supported by care staff. Those residents who are using the respite service can Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 13 continue with their normal daily arrangements but often view their stay at the home as a holiday. Previous reports also evidenced that the home plays an active part in the local community, having their own community centre and extensive grounds where regular events take place some of which are fundraising. There is a regular swimming session at the local swimming baths and residents are well known and made welcome at local pubs and restaurants some of whom help with raising monies for holidays. Information received from the provider in the homes pre-inspection questionnaire showed that daily activities are undertaken including celebrating residents birthdays, rides out, youth club, barbeque, tom bola and Gateway club. The home has a programme for holidays with a number of residents travelling aboard for holidays to Disneyland Paris and Spain. Previous inspection reports also identified that families play an active role in the home and a number belong to the Bungalow committee and join in activities. Maintaining links with friends and relatives is included in the care planning for permanent residents and arrangements are made to take residents to see families where they are unable to come to the home. The manager confirmed that activities and outings are arranged with residents and families This inspection found that some residents have keys to their rooms and they confirmed that neither staff nor other residents can enter without getting their permission. They also stated at this inspection that they are involved in learning daily living skills by keeping their rooms clean and tidy, cleaning the mini-bus, budgeting and undertaking voluntary work in a charity shop. A resident commented that ‘ I go out on my own; I have complete freedom, as well as a key to my door. I admire the carers for giving me respect’. This resident also confirmed that she undertakes work in a charity shop. Comments received from residents in their surveys were that ‘I like going to visit my brothers, watching soaps on television, going out with friends and visiting my mum’. Other comments were that ‘I like hoovering and watching television’, ‘I like the pub, shopping and a game of pool’. Evidence was seen throughout the home of photographs of residents on holidays, undertaking activities and joining in birthday celebrations, as well as Christmas and Halloween parties. The homes pre-inspection questionnaire showed that a wide range of meals are available to residents and residents files evidenced that residents dietary needs are assessed prior to admission. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 14 Previous inspections found that residents prepare a menu for the following week on Sundays, which is used as a guide as residents frequently change their mind on the day. A record is made of each meal provided which showed that a varied, healthy and balanced diet is available. The regulator joined two residents for lunch and comments made by one was that ‘the food is very good’ and you can’t get better. They ask you want you want and when you want it. Other places I have been to didn’t give you choice. We also go out for meals or get a take-away in’. The meal on the day was well presented, hot and very tasty. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health care needs are met and there are clear medication policies and procedures in place. Personal support is not adequately recorded in residents care plans. EVIDENCE: Previous inspection evidenced that residents health care needs are included in care plans. Those appointments for residents using the respite service will be met and the homes doctor contacted if needed. Residents attend the well person clinics and community based health care professionals attend the home when needed. There is a weekly reflexology session held in the home. Information supplied by the provider prior to this inspection evidenced in residents medical appointment sheets that appointments are made with GPs, chiropodist and reflexology. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 16 A pharmacy inspector carried out a specialist visit on 06/12/06 and no requirements were made at this inspection relating to administration of medication. The providers training profile evidenced that all staff have undertaken safe handling of medication in 2006. Due to the satisfactory inspection carried out by the pharmacist and the past positive inspections of medication no inspection was undertaken during this visit. The manager stated that none of the current residents are able to administer their own medication. Previous inspections have shown that all staff are inducted on how to promote and maintain residents privacy and dignity when providing personal care as many can not communicate how they would like to be supported. A care plan received prior to this inspection outlined the personal care required by a resident in relation to showering/bathing. The care plan also included the risk assessment in undertaking this task. However, this care plan did not address the issue of maintaining the resident’s privacy and dignity whilst undertaking this task. In addition there was no mention of social engagement with the resident or how he liked these tasks to be undertaken. No mention was made if prompts could be used or how this resident’s independence is promoted. The home does not have a intimate care policy which would inform carers in carrying out intimate care tasks with residents. A carer stated that he maintains residents privacy and dignity by closing doors and curtains and talk to the resident to keep him focused when doing tasks. One resident confirmed that she undertakes all her own intimate care needs as she is very independent. She also said that ‘ it is very private here and staff are very good at respecting privacy’. Observations made by the regulator during this inspection was that residents are able to express their needs and appeared happy and free to do so. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not empowered by the homes complaints procedure. The home takes the protection of residents seriously and acts to support and protect residents. EVIDENCE: Previous inspections have found that the home has a complaints procedure and this is displayed in picture format in each bungalow. The complaints book was also seen on previous inspections and did not contain any complaints. Information received prior to this inspection included a resident’s complaints letter and a pictorial poster showing who a resident could see if they were not happy. The home does not have a user-friendly format for the recording of complaints and may consider that this needs to be undertaken to ensure that information regarding complaints is appropriately recorded and resident are a part of this process. The provider has a copy of the Adult Protection Procedures in the office and staff have been provided with safeguarding vulnerable adults training in 2006. The home has a whistle blowing policy and those care workers seen were aware of this policy and knew what action to take if they became concerned for the well being of a resident. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 18 The homes service history held by the commission showed that the provider had reported an allegation made by a resident to the commission and social service department. This allegation was investigated and was seen to have been unfounded. The manager said that there have not been any further allegations of abuse since 15/06/06, which was reported to the appropriate agencies. A resident stated that ‘I have never made complaint here, only good things here. I feel safer here than anywhere else and nobody can get me. I’ll be safe here for the rest of my life’. Resident’s surveys showed that all fourteen knew who to speak to if they were unhappy. They also knew about how to make a complaint. A carer confirmed that he had undertaken safeguarding vulnerable adults training and that he was aware of the whistle blowing policy. He also stated that he would report to the manager any concerns he might have regarding the welfare of residents. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a homely and comfortable environment for residents to live in. The home is clean and tidy with a pleasant smell throughout the home. EVIDENCE: A resident showed the regulator around the home and it was found that there are two bungalows, which are set in a large garden area. Two residents bedrooms were seen and found to be domestic in character, comfortable, bright, clean and maintained well. Each bungalow has a conservatory, one being used as a sensory room and the other a games room. Not all of the bedrooms were seen as some residents were out and had not given permission for their rooms to be visited. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 20 All bedrooms seen were comfortable, personalised and equipped to meet the needs of the residents. Since the last inspection an Arjo bath has been installed as well as a walk in shower. Other improvements include a kitchen being re-fitted. The home has a maintenance book as well as a programme of refurbishment. Risk assessments are undertaken on all residents living in this environment. A resident confirmed that she couldn’t wish for a cleaner place, she went on to say that ‘I clean my own bedroom and do my own ironing and washing’. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a well-trained and knowledgeable staff team who are fully vetted prior to being appointed. EVIDENCE: Information received prior to this inspection evidenced that new care staff are fully vetted by the provider. This inspection found that recruitment practices were in place and one staff file contained all of the documentation required by law. It was also found that interview notes of a new care worker employed at the home were kept for possible future reference. One carer stated that he had undertaken the homes recruitment process and confirmed that references and criminal record bureau checks were acquired prior to stating work at this home. Information received from the provider prior to this inspection showed that there are guidelines relating to the recruitment of staff. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 22 Previous inspection has found that each worker in the home has been given the General Social Care councils pack relating to the registration of care workers and the philosophy of the Care Council for all social care homes. The homes training plan and pre-inspection questionnaire was received by the commission and evidenced that training was undertaken in 2006 and training is planned for 2007. Also 60 of staff have completed NVQ (National Vocational Qualifications) training level 2 and three are completing level 3. The deputy manager is working towards NVQ 4 in care. Evidence was also available that training specific to this client group has also been undertaken. The provider employs thirteen carers, one bank staff worker, one fundraiser and a handyman. One carer said that he has worked in this home since 2004 and has completed the homes induction training and completing NVQ level 2 and is now working towards completing NVQ level 3. He also stated training undertaken adult protection training, safe handling of medication, care practice, dementia, peg feeding and emotional issues. A resident stated that ‘staff are very well trained and I have a key worker who I have been on holiday with, she is lovely’. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by good health and safety and quality assurance systems. Resident’s who live in this home benefit from the leadership and management of the home. EVIDENCE: The manager has worked for this company for seventeen years and has achieved the registered managers award and NVQ level 4 in care. She has an open door approach to both residents and staff who require support and guidance Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 24 The home has adopted the Quality Tree framework to provide feedback from residents on the services they receive. Weekly residents meetings are held and relatives are actively involved in the overall running of the home as a number are members of the Board of Trustees. The homes surveys were sent out in early January 07 and eighteen had been returned. Those seen evidenced that a positive view is held of the work undertaken by the staff at this home as well as the management input. The manger stated that the surveys would be analysed and put on the notice board for the information of residents and visitors. She also said that surveys also go towards the providers business plan. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. The homes pre-inspection questionnaire evidence that fire alarm, fire drills and emergency lighting checks are carried out. Staff also receive fire training as part of the homes initial training and as a regular training event. The homes self-assessment shows that ‘policies and procedures are read and signed by staff and that they inform practice’. The homes pre-inspection questionnaire evidenced that; gas safety inspections have been carried out, electrical wiring checks, and portable electrical equipment checks. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 3 x x 3 3 Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 26 No 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 YA2 Regulation 14(a) Requirement The home must amend its policies/procedures to reflect that the home must carryout a pre-admission assessment with or with out other agencies The provider must confirm in writing to the service user that the home is suitable for the purpose of meeting the service users needs in respect of his health and general welfare. The provider must ensure that pre-admission care needs assessments are carried out using a format suitable for this purpose. The provider must consult with service users or their representative and notify them of any revision in their care plans or risk assessments and obtain a signature confirming that the changes are agreed. Care plans must address the issue of maintaining a resident’s privacy and dignity whilst undertaking intimate care tasks. They also need to mention social engagement with the resident during undertaking these tasks. DS0000008649.V326995.R01.S.doc Timescale for action 26/03/07 2. YA3 14(d) 26/03/07 3. YA3 14(b) 26/03/07 4. YA6 15 (c ) 26/03/07 5. YA18 12 (4)(a) 26/03/07 Cherry And Rowan Villas Care Home Version 5.2 Page 27 6. YA18 12(4)(a) Care plans also need to mention the use of prompts to ensure that a resident’s independence is promoted. The provider must introduce an intimate care policy for the guidance of all carers when undertaking intimate care tasks with residents. 26/03/07 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 YA22 Good Practice Recommendations The provider should have a complaints procedure, which empowers residents. Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. Extracts may not be used or reproduced without the express permission of CSCI Cherry And Rowan Villas Care Home DS0000008649.V326995.R01.S.doc Version 5.2 Page 29 - 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!