Inspection on 29/01/08 for Cherry Trees

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Trees 13/01/09

Cherry Trees 26/06/06

Cherry Trees 11/02/06

Cherry Trees 18/04/05

Cherry Trees 06/01/05

Cherry Trees 15/07/04

Cherry Trees 08/07/03

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Cherry Trees Simmonite Road Kimberworth Rotherham South Yorkshire S61 3EQ Lead Inspector Ms Stephanie Kenning Key Unannounced Inspection 29th January 2008 09:30 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 DS0000003076.V358808.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. DS0000003076.V358808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Trees Address Simmonite Road Kimberworth Rotherham South Yorkshire S61 3EQ 01709 550025 01709 556308 cherrytree@exempalhrc.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) Cherry Health Care Limited Post vacant Care Home 66 Category(ies) of Dementia (66), Old age, not falling within any registration, with number other category (66), Physical disability (66) of places DS0000003076.V358808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP; Dementia - Code DE and Physical disability - Code PD The maximum number of service users who can be accommodated is: 66 26th June 2006 2. Date of last inspection Brief Description of the Service: Cherry Trees Care Home is situated in the Kimberworth Park area to the north west of Rotherham. It is on the fringe of a large housing estate. The home was purpose built and facilities are provided on ground and first floor level; access to the first is by a lift. Cherry Trees is registered as a care home that provides personal and nursing care for 66 older people. There are four units within the home. Two of the units provide nursing and residential care: - 32 beds in total. The remaining two units offer care for people who have dementia: - 34 beds in total. There is a level garden area to the rear of the home suitable for access by pedestrian and wheelchair users, and access to the garden is gained through the conservatories. Cherry Trees Care Home is located in the residential area of Kimberworth Park, a suburb of Rotherham. The home is on a bus route, bus numbers 39,41,42,43 and within a short walking distance of bus stops. Car parking is provided for several cars to the front of the home along with street parking Fees range from £343 to £581 at time of visit 29/01/08, dependent on needs assessment. Additional charges are made for hairdressing, Chiropody, Optical, Dental services, specialised toiletries and magazines etc. The registered person makes information about the service available to residents and their families via the home’s Statement of Purpose and the Service User Guide. A copy of the inspection report is made available at the home. DS0000003076.V358808.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes Since the previous inspection of 27th June 2006 a record has been kept of notified incidents and events at the home. Prior to the recent unannounced visit of January 29th 2008, information was provided in The Annual Quality Assurance Assessment, completed by the previous manager, 1 service user survey, five relative surveys, and 5 staff surveys, along with other information known about the home. The site visit from 9.30 to 4.55pm on January 29th, also contributed to this report. A new manager, Chris Storr, has been in post for about 2 months. During the visit the inspector spoke to six service users, two relatives, five staff and the manager, and would like to thank all for their openness, and contribution to the findings. The inspector was pleased to note that all people spoke positively of the ongoing support provided by the staff. For about 2 hours the inspector sat in one of the lounge areas and observed what life in the home was like on one of the dementia units, by doing a Short Frame Observational Inspection (SOFI). Observations confirmed that people using the service were comfortable and at ease in the company of the manager and staff whom they said were approachable, supportive and sensitive to their needs and feelings. There were some examples of where practice could be improved and this was discussed in the feedback to the manager. A number of records were examined which included, medication records, three care plans of people currently at the home, and menus. Records relating to staff recruitment, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Feedback on the findings was given to the manager before the inspector left the home. Twenty complaints had been dealt with in the past 12 months, covering various issues including staffing levels, hazards to safety, food, items missing, staff attitude, lack of communication, and laundry problems. Records show that they were responded to quickly with satisfactory outcomes. The new manager has looked at the issues again as part of her plan to make improvements at the home. The Provider and senior management of the company were aware of the number of issues at this home and were visiting frequently to assist and support the new manager. The inspector would like to thank everyone involved in the inspection for their help and support. DS0000003076.V358808.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: They must make improvements in the way documentation is completed to reflect what has happened to individuals each day. The care plans need to be reviewed and revised to include information from carers and supporters, and to promote the wellbeing by developing activities based on individuals interests and abilities. Although the home generally meets the minimum staffing levels required, they need to ensure sufficient staff to improve and develop the home, and to facilitate good communication between staff, for the wellbeing of people in their care. In addition communication with people using the service must be improved, particularly those people who have communication difficulties. The planned programme of training identified must be carried out to ensure all staff members are up to date in the skills and knowledge required to do their job. DS0000003076.V358808.R01.S.doc Version 5.2 Page 7 It was unclear how people would have the recommended levels of 5 portions of fruit and vegetables a day, and this should be monitored and promoted for the health and wellbeing of people using the service. 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. DS0000003076.V358808.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000003076.V358808.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standard 3. Intermediate care is not provided at this home. People do not move in to the home until a full needs assessment has been undertaken and the home can confirm they can meet the needs of that individual. EVIDENCE: All people moving in to the home have their needs assessed and they have been assured their needs could be met prior to admission. Detailed full needs assessments were completed for the people whose files were read. These had been completed by the referring social worker, or the Registered Manager for those people self- funding. Relatives confirmed that this process happened prior to admission and that their relative had opportunities to visit the home prior to making a decision about moving there. People had been given DS0000003076.V358808.R01.S.doc Version 5.2 Page 10 information about the home and a copy of the previous CSCI report was available to read at the home. The AQAA states that information about the home could be in different formats to help potential residents, including the service user guide, and they plan to do that in the near future. DS0000003076.V358808.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 7, 8, 9 and 10. People’s individual personal and health care needs are met to a basic level, staff support them in this, and respect their privacy. Medication systems follow clear guidelines that promote the safety of residents, and allow some people to be independent. EVIDENCE: Care plans are comprehensive, covering a wide range of needs, and are easy to read and understand. Within case tracking were some areas that could be developed, such as social activities. For example one persons interests had been cooking, gardening and embroidery. The care plan stated that due to cognitive impairments she was unable to follow her interests. However she did attend some social activities within the home, and it is possible that she may be able to observe cooking, or discuss it, and the same for her other interests. DS0000003076.V358808.R01.S.doc Version 5.2 Page 12 The care plans could identify some goals to be tried for. A similar issue was found within another care plan where someone was unable to follow their chosen religion due to cognitive impairment, and there could be ways of enabling this person to be more involved. Care plans were regularly reviewed and updated. Daily reports could be improved to say what happened to that individual that day. Phrases like ‘assisted with hygiene needs’ and ‘safety maintained’ do not describe what happened. One member of staff was able to explain how the care staff had devised a way of dealing with a difficult situation when bathing, which had helped the person using the service a great deal. This was not part of the care plan, or review, and shows that the care staff and nurses overseeing the care need to be communicating and jointly reviewing the people in their care. There were a number of ill people being cared for in bed, with pressure relief mattresses in place, and regular care given by staff. All of these people appeared to be very comfortable and no one at the home had a pressure sore. Regular visits by GPs and community nurses were noted in documentation, and visits by chiropodists, dentists, and opticians were also recorded. One person went to hospital for an appointment during the visit, and a staff member will usually accompany to support whenever staffing levels allow. The SOFI observation identified that people were getting their basic health and personal care needs met, with regular drinks being offered and people taken out of the room for personal and health care reasons. Staff members were mainly discreet about the care they were taking people for, but sometimes did not give sufficient information about where they were taking someone, and one person was wheeled out of the room with no explanation at all. Some people had a lot of good attention from staff members including sitting with them and chatting about something that was happening or stroking their hand to calm them. Several people were noted to be sleeping for a majority of the observation period, but this was not felt to be due to sedative medication. Staff commented that they were busy meeting basic care needs and responding to those able to voice their demands, but were aware that others needed more stimulation. The presence of a visiting dog during some of this time was noted to cause several people to take notice and communicate with the dog, when they had shown little interest in their surroundings previously. A lunchtime medication administration session was observed, and was noted to follow safe practices. Records were being completed correctly, and people were asked if they required medication such as painkillers where prescribed. Storage facilities were suitable and organised, though some other items were found within the controlled drug storage, but were removed immediately. Staff members administering medication undertake training provided by the company. DS0000003076.V358808.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 12, 13, 14, and 15. People are able to make some choices about their lifestyle and activities, but some people’s individual experiences are limited. EVIDENCE: People living in the home were able to choose different aspects of their daily life such as when to get up, where to sit, whether to join in a social activity, what to have from the menu and some preferences were recorded on care plans. The SOFI observations confirmed that people could make some of these choices. Two activities staff did a variety of activities including a coffee morning that included a reminiscence session, and had visitors involved. The activities staff appeared very skilled in their work and in dealing with people with dementia. Unfortunately they were unable to help all the people living in the home every day, as they were too few for too many. This was confirmed DS0000003076.V358808.R01.S.doc Version 5.2 Page 14 by comments in surveys such as ‘there is not much stimulation’, however it was recognised that activities had recently improved. Sometimes people went on outings to the pub or shopping, and entertainers were brought in to the home. There is a new mobile sensory unit for use with bedbound residents. It was observed that care staff sometimes sat with individuals and engaged them in conversation, which was important for some people not involved in activities. This happened more frequently where the person using the service could communicate well. As stated in section 2 there could be suggestions to improve the activities linked to the interests of people with dementia, for example cooking or gardening related activities. A number of people remained in their rooms throughout the day and were observed to watch TV or read, following their preferences. Some people were ill and spent the day in bed, relying on staff and visitors for all their stimulation. Relatives visited and said that they were made welcome at any time of the day and encouraged to join in events at the home. The lunchtime meal, of sandwiches and cake, was well presented, with a choice of sandwich fillings and breads, and the cake was homemade. It was observed that no fruit or vegetables were served at this meal, and though there were fruits and vegetables on the menu for the day it would be difficult to ensure that people were getting at least 5 portions as recommended by current guidelines. Staff stated that people were offered additional fruit in the form of juices and smoothies, including where people were identified as needing additional nutrition for weight loss. It is recommended that this be monitored to ensure that people are getting sufficient. The menu choices had recently been updated, and incorporated the wishes of people living at the home and the guidance of the catering manager. Special diets are catered for including arrangements for Halal food. A company catering inspection was being held at the home at the same time as the CSCI inspection visit, and so a kitchen inspection was not undertaken at this time. Two complaints about food had been made in the past 12 months, one referring to the quality and one to the quantity. These specific issues were dealt with and changes made. Feedback from people using the service now is positive, with comments like, ‘the food is good’, and ‘the meals are nice’. DS0000003076.V358808.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 16 and 18. People who use the service are able to express their concerns and are confident that they will be listened to, and action taken. EVIDENCE: The home has had about 20 complaints and two adult protection investigations during the past year. The complaints have been about care issues, food quality/quantity, lack of staffing, staff attitude, staff competence, laundry, items missing, falls, health and safety issues, and communication. The manager or another company representative investigated all the complaints. Some were upheld and action has been taken to change and improve things, for example, people at risk of dehydration now have detailed intake and output records for staff to assess. The new manager has been looking at where things were going wrong and working to improve them. She has particularly looked at the basic care of people, staff recruitment, training, supervision and appraisal of staff and has set up a 3 months plan of training. She has implemented heads of department meetings to look at areas of responsibility, and has become involved with relatives meetings and is getting to know relatives so DS0000003076.V358808.R01.S.doc Version 5.2 Page 16 that she is approachable. She is aware of further development areas such as record keeping, and core values that will be incorporated into the training and that will improve the quality of service received by the people in their care. Relatives and people using the service said that the management team at the home were approachable and they would take any concerns to them. There were very few criticisms of the home in the surveys and when talking to people. The new manager was praised for being proactive and understanding. Staff members feel that standards in the home are improving already, meaning that people in their care are being looked after better. Social Service staff as required conducted the adult protection investigations and the usual processes were followed by the home. Care workers have had training on the safeguarding of people in their care and gave some examples of care that was not right. They knew to report it to a senior person at the home. DS0000003076.V358808.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 19 and 26. People live in a safe, well maintained, clean and comfortable home. EVIDENCE: The home was warm, clean, bright and odour free throughout the day. People living at the home and their relatives were happy with their rooms, many of which had a number of personal items in, and with the rest of the building. There is a pleasant garden area with seating and other features, and this can be accessed from the ground floor. A range of aids and equipment were seen in use. Each of the bedrooms has an en-suite toilet and washbasin and there are bathrooms available in each area of the home. DS0000003076.V358808.R01.S.doc Version 5.2 Page 18 There is an ongoing programme of maintenance, servicing, redecoration and refurbishment, which keeps the appearance of the home good. It was stated that changes to the laundry have helped to improve the efficiency and to provide a better service, in response to some complaints in the past year. The driveway has been adapted for users of wheelchairs to give easier access to and from the home. DS0000003076.V358808.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 27, 28, 29 and 30. People are generally satisfied with the care they receive, and most staff members are well trained and competent. EVIDENCE: The company policies and procedures are followed regarding recruitment, with relevant checks such as references and CRB and POVA checks recorded. Application forms have been modified to ensure equality and diversity is considered, and all staff members have completed a full weeks induction, where equality and diversity are discussed relevant to their work with individuals. There has been a high turnover of staff since the last inspection visit, with the AQAA stating 22 had left in 12 months. This was recognised by comments in the surveys such as ‘fair turnover of carers recently’, and may have led to inconsistency of care. Some people were concerned about staffing levels, and that sometimes there were no staff present for significant periods of time when they visited. The new manager has looked at this and reorganised staff breaks, DS0000003076.V358808.R01.S.doc Version 5.2 Page 20 so that this should not happen again. Observations during the visit confirmed that staff were busy, and whilst able to meet basic needs had little time to plan and work on developments or improvements. Evidence of this is in section 2 when carers were doing work that had not been discussed or incorporated into the care plans. There did not appear to be handover periods built in to the shift pattern, instead this relies on people passing information over quickly or working longer than they are paid for. Rotas show that most shifts are covered to meet the minimum requirements and that agency cover is used when permanent staff members are unable to cover. There are still vacancies being recruited to, but most problems arise when people are ill and off work at short notice, particularly at night, and the company have set up a system of relief staff to help with this. Recruitment has tried to provide a skill mix of staff on the units, and more workers’ are undertaking qualifications. About 55 of care staff were said to have completed, or were undertaking an NVQ level 2 or above. Domestic staff members all have NVQ training, and the kitchen manager is taking advanced food hygiene. There is also a programme of in-house training in-house for updates in such areas as moving and handling, though some areas are not as up to date as they could be. The new manager has a plan to bring everyone in line with the requirements and in particular wants to focus on improving values and attitudes, and communication skills, particularly with people who have dementia. DS0000003076.V358808.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 31, 33, 35 and 38. The management of the home have implemented changes and systems to improve the lives of people living in the home. EVIDENCE: The new manager is Chris Storr, who has a nursing registration, a degree and the Registered Managers Award. She has many years experience of working with older people, including training staff and managing homes. Until recently she was the registered manager of another home within the company and moved to Cherry Trees at the end of November 2007. Her application to CSCI for the Registered Manager of Cherry Trees is expected. DS0000003076.V358808.R01.S.doc Version 5.2 Page 22 Since taking up the post she has identified a number of areas for improvement and has implemented many changes. She has the support of more senior managers who visit regularly. People were pleased with changes she has made and found her welcoming and helpful. She has changed staff routines, such as taking meal breaks separately so that they are more available to people using the service. She has looked at the basic care of people living in the home as a priority to ensure people were getting the care they need. She has introduced clearer records for people who are not eating or drinking well, so that they can be monitored more closely. She has looked at problem areas and made a plan to improve them, for example staff training, appraisals and supervision, and communication with relatives. She has used existing meeting forums, and monitoring systems to check that she is going in the right direction, and has had good feedback from relatives. She has implemented a heads of department meeting so that each area of responsibility can be looked at and the relevant people can make improvements. She has also had to implement the company disciplinary procedures and take action as required, showing that she is pro-active in dealing with poor practice. DS0000003076.V358808.R01.S.doc Version 5.2 Page 23 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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 3 DS0000003076.V358808.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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. 4. 5. 6. 7. Refer to Standard OP7 OP7 OP10 OP12 OP15 OP27 OP30 Good Practice Recommendations Review and revise care plans to promote the wellbeing of people using the service regarding social care needs and involving appropriate supporters. Improve daily recordings to be specific about the individual. Improve communication with people using the service, particularly with those people who have communication difficulties. Develop activities further based on individual interests and abilities. Monitor and promote the intake of 5 portions of fruit and vegetables each day. Review staffing levels to provide time to improve and develop the service, and aid communication between staff. Ensure the training plan is carried out to ensure staff members are up to date in the skills and knowledge they need to do their job. DS0000003076.V358808.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 DS0000003076.V358808.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!