Inspection on 27/06/05 for Cherry Tree Lodge

This inspection was carried out on 27th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cherry Tree Lodge 18/04/07

Cherry Tree Lodge 20/04/06

Cherry Tree Lodge 08/11/05

Cherry Tree Lodge 30/03/05

Cherry Tree Lodge 17/08/04

Similar services:

Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Cherry Tree Lodge 133 Macauley Drive Lincoln Lincs LN2 4ET Lead Inspector Mick Walklin Unannounced 27 June 2005 09:30 th 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Cherry Tree Lodge Address 133 Macauley Drive Lincoln Lincs LN2 4ET 01522 545580 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) Prime Life Limited Mrs Laura Pamela Bucke Care home with nursing 19 Category(ies) of LD Learning disability (18) registration, with number LD(E) Learning disability - over 65 (1) of places Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1) To admit one LD(E) service user on a named basis only Date of last inspection 30 March 2005 Brief Description of the Service: Cherry Tree Lodge is situated on a residential housing estate approximately one and a half miles north of the city centre of Lincoln. It is close to local facilities and has public transport links to the city centre.The home is registered to accommodate 19 people with a learning disability. Accommodation is provided within a large two-storey house. The first floor is accessible by lift. There are 15 single bedrooms, and 2 double rooms, none of which have ensuite. There are 2 lounges, 1 sensory room and 1 dining room. There are 8 toilets, 2 bathrooms and 1 shower.The grounds are enclosed and private. They are laid to lawns at the front and side of the property, with car parking to the rear. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, and lasted 8 hours. At the initial inspection, all residents and most staff were on an outing, so a follow up visit was arranged to complete the inspection. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A tour of the building was conducted with the manager. Documentation was inspected. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 6 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 Standards Statutory Requirements Identified During the Inspection Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 There are satisfactory procedures for the assessment and introduction of residents prior to admission, ensuring that their needs are met. EVIDENCE: Two residents have been admitted since the last inspection, and their records described their care needs, and gave sufficient information for staff to formulate a plan of care. Staff were able to describe in detail the care needs of the individuals concerned. One resident had transferred from another Prime Life home with his existing documentation, and he said that he had settled in well and was enjoying living at the home. There are procedures for accepting emergency admissions through the Learning Disability Team, but only if they are able to provide the manager with sufficient pre-admission information. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9. Care plans contain sufficient information to ensure that the care needs of residents are met, and risk assessments support residents in leading as independent lifestyle as possible. EVIDENCE: All residents files inspected contained clear information for staff relating to the care needs of residents. Assessments cover all aspects of daily living, and each assessment generates a care plan and risk assessment if applicable. Care plans have daily records, but it was not clear when some had been reviewed as no evaluation sheet was included. All residents have a learning disability, and most are unable to agree or contribute to their plan of care, so the manager has written to all relatives, asking them if they wish to contribute to the plan. Risk assessments on file enable residents to live as independently as possible, whilst ensuring that risks are minimised. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 17. There have been improvements to the provision of social and leisure activities, so that there is are a variety of activities for residents to participate in. EVIDENCE: At the time of the first part of the inspection, all but one resident were either at day services or on an outing. The manager said that there had been an increase in outings, and three had been planned for June, together with a holiday to Butlins. Staff commented that there appeared to be more outings, with a bus being available every two weeks, and that the daily activity timetable was being followed. One member of staff is allocated as activity coordinator for each shift, and those residents not having a regular day placement have the option of participating in a variety of in-house activities. Two residents said that they were generally happy with the activities available, but one said that she sometimes gets bored. The cook demonstrated a good knowledge of individual dietary needs, and explained how individual preferences are catered for. Two residents said that they were satisfied with the quality and variety of the food served, and mealtimes appeared well organised and relaxed. Staff were observed to be Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 10 offering a high level of encouragement and support to a resident who had refused to eat his meal, including offering food alternatives. Some information relating to residents conditions and nutritional needs was displayed in the dining room. As this was of a confidential nature, the manager was asked to remove it. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20. There are good links with health care services, ensuring that health needs of residents are met. EVIDENCE: There was widespread evidence of referrals to health care services to meet residents needs. All residents are registered with local GP surgeries, and letters relating to outpatient appointments, and referrals to specialists were on file. There are satisfactory arrangements for optical and dental provision. The previous inspection highlighted that there had been two occasions where medication had been administered and not signed for. The manager had raised this matter in supervision, and administration records were satisfactory on this occasion, as were storage and stocktaking arrangements. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23. There are satisfactory procedures for handling complaints and allegations of adult abuse, ensuring that residents are protected. EVIDENCE: There is an accessible complaints policy available in written and symbols format. These are displayed in areas of the house. The policy is also contained in the staff policy handbook, and staff were able to describe the procedure, should they receive a complaint. There have been no complaints since the last inspection. One member of staff said that she had not received adult protection training, but there was evidence that she had received general training on policies and procedures during induction. It is recommended that adult protection is covered as a separate subject on induction. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The home is generally well maintained, with some improvements having been made. It provides residents with a homely environment, but some maintenance issues need to be addressed. EVIDENCE: The maintenance requirements from the last inspection have all been rectified. The home was generally well maintained, clean and brightly decorated. Windows have been replaced throughout the home, and these offer better sound and draft proofing for residents. New furniture has been purchased for one of the lounges, making it more homely. The following maintenance issues were identified: • • Two bedrooms have broken door stops, and there was damage to the walls caused by the door closures. There is a large pile of garden waste in the corner of the garden, and this must be removed. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 36. Recruitment and selection procedures have improved, and now offer protection for residents. There are sufficient staff to meet the needs of residents. EVIDENCE: The home is fully established at present, and daytime staffing levels are maintained at 4 per shift, plus a qualified nurse, housekeeper and cook. A visiting relative said that he was very satisfied with staffing arrangements within the home. An administration assistant is employed, and the manager said that this has aided in the organisation of the home. A Deputy Manager was appointed recently, but did not start. Training is co-ordinated centrally within the company, and spreadsheets for training undertaken and training due are kept. Prime Life has introduced the Learning Disabilities Awards Framework (LDAF), and a majority of carers were undertaking this. Four staff have commenced NVQ level 2, but no staff have completed this at present. Staff are now receiving regular supervision, and the manager has a record of supervision undertaken. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 & 42. Documentation, policies and procedures are of a satisfactory standard, but some health and safety issues were identified, which could put residents at risk. EVIDENCE: Inventories of residents possessions have been completed since the last inspection. A new format for Regulation 26 reports has been introduced, and monthly visits conducted. Further guidance relating to supplying a copy of these reports to the Commission is awaited. The previous inspection highlighted that staff were being employed prior to obtaining satisfactory references and Criminal Records Bureau checks. Four files were inspected, and all contained the information and documents necessary for the protection of residents. The following health and safety issues were identified: Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 16 • • • • • • One of the fire exits is through a bedroom, and this door is fitted with a lock. The Fire Officer has advised the Commission that either a break glass point with a key is installed in the vicinity of the door, or the door be secured with special bolts that allow access in an emergency. The sluice room was unlocked, despite large amounts of Steradent being stored in there. The fire extinguisher in the sluice room was not attached to the wall. Topical lotions belonging to individual residents were stored in bathroom cabinets, and one tub of lotion was found on top of a fire extinguisher. These are the property of the residents concerned, and should be stored appropriately in individual bedrooms. A bottle of hand-wash, with a hazard warning label, was stored on a radiator in the hallway. The manager explained that this was for visitors to wash their hands, but this must be stored securely when not in use. There are some large paving slabs propped against the wall in the garden. The manager has requested that these be removed, and risk assessed the situation on the day of the inspection. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cherry Tree Lodge Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 2 x C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 18 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. 2. 3. Standard 24 42 Regulation 23(2) 13(4) & 23(4) Requirement Timescale for action 30/11/05 The registered person must ensure that the maintenance issues identified are attended to. The registered person must 30/11/05 ensure that the health and safety issues identified are attended to. 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. Refer to Standard 23 6 Good Practice Recommendations It is recommended that adult protection is covered as a separate subject on induction. It is recommended that all care plans are reviewed at least every six months to reflect changing needs. Cherry Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection Unity House, The Point Weaver Road off Whisby Road Lincoln, LN6 3QN 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 Tree Lodge C53-C04 S2605 CherryTreeLodge V234481 270605 Stage 4.doc Version 1.20 Page 20 - 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. 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