Inspection on 07/08/06 for Cherry Trees Care Centre

This inspection was carried out on 7th August 2006.

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

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

Other inspections for this house

Cherry Trees Care Centre 09/02/06

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Snydale Care Home

Abbey The

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Cherry Trees Care Centre Cherry`s Road Cundy Cross Barnsley South Yorkshire S71 5QU Lead Inspector Christine Rolt Key Unannounced Inspection 7th August 2006 08:45 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherry Trees Care Centre DS0000066494.V308140.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 and 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 Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Trees Care Centre Address Cherry`s Road Cundy Cross Barnsley South Yorkshire S71 5QU 01226 704 000 01226 704004 cherry.trees@fshc.co.uk www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Julie Bassendale Care Home 89 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) Category(ies) of Dementia (34), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (34), Old age, not falling within any other category (45), Physical disability (10) Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for 34 service users in the category DE/E Dementia Elderly or MD/E - Mental Disorder Elderly. These service users must be aged 60 years and above, however, three service users may be accommodated on this unit aged 55 years and above. The accommodation for these service users is on the lower ground floor in a separate unit. The home is also registered for 45 service users in the category OP Older People. The accommodation for these service users is on the ground and first floor. The OP - Older People service users must be aged 60 years or above. The home is also registered for 10 service users in the category PD Physical Disability. These service users must be accommodated on the ground floor in a separate unit. With the exception of the PD - Physical Disability Unit, the care staff, qualified nurse staffing levels and the Manager supernumerary time must be maintained at, at least the levels agreed previously with Barnsley Metropolitan Borough Council and Barnsley Health Authority. In the PD - Physical Disability Unit, a registered general nurse must be on duty in the unit 24 hours a day. Staffing levels must at least comply with the `Residential Forum Care Staffing in Care Homes for Younger Adults`, published April 2002. The registered Manager must undertake training in working with service users with Dementia and Mental Health problems. 9th February 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Cherry Trees is situated in Cundy Cross and is 3 miles from Barnsley. The unit is on three levels, is purpose built and has adequate car parking space. The home is registered to care for residents requiring personal and nursing care in the categories of dementia, old age and physical disability. The physical disability unit was registered by the NCSC and opened in 2003. Within a moderate walk of the home there is a full range of amenities including a variety of shops selling provisions, a chemist, optician, hairdresser, post office and newsagents. The fees were from £322.50 to £733.00 per week. Hairdressing, private chiropody and toiletries were not included in the fees. Outings arranged by the home were funded mainly by the home’s fund raising efforts but residents were expected to pay a minimal charge towards the outing. The registered manager supplied this information in the Pre-Inspection Questionnaire dated April 2006. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 08:45 am to 4.15 pm on 7th August, 11.00 am to 3.20 pm on 8th August and from 12.30 pm to 2.45 pm on 14th August 2006. The registered manager, Mrs. Julie Bassendale was present on two of the three days and provided assistance. The majority of the residents were seen and chatted to during the site visit, and of these, seven were asked detailed questions about their opinions of the home and four were tracked throughout the inspection. Four members of staff were interviewed. Seven relatives, a nursing auxiliary, a community support worker and a social worker were also asked for their opinions of the home. Comment cards were sent to ten residents and of these four were completed and returned. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, residents, relatives and other stakeholders for their assistance and co-operation. What the service does well: The home had a welcoming atmosphere. It was clean and there were no offensive odours. Residents and their relatives were happy with residents’ care. Comments included “Don’t think I could have found a home that cares so much” The dementia unit had an activities room where various crafts were displayed. An activity co-ordinator was employed on the dementia unit and residents were participating in the activities. The manager provided good leadership and ensured that all staff were trained to do their jobs. All mandatory health and safety training was up to date and staff had undertaken other training relevant to their work. Comments about the staff were all positive. General impressions of the home were “I like coming (to this home)…it’s good” “One of the better ones”, “Nice atmosphere”, “Lots of things to be proud of”, “Lovely atmosphere” and “Happier now than I’ve been for years” Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 6 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1(YA 1), 3 (YA 2) and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. This home does not provide intermediate care for older persons. Prospective residents had the information they needed to make an informed choice about where to live. Residents only moved into the home after their needs had been assessed and been assured that the home could meet their needs. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 9 EVIDENCE: Residents and their relatives said that they had viewed the premises, received a pack of information about the home including the Service User Guide and had their questions answered. Residents and relatives comments for choosing this home were “Convenient”, “Does both residential and nursing”, “Friendly” “Recommended”, “Newer and more space and nice light rooms” and “Visited home and three others to assess suitability”. The last inspection report was displayed in the foyer. issued with copies of the Service User Guide All residents had been Residents were assessed prior to admission to the home and copies of the assessments were seen on residents’ files. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7 (YA 6 & 9), 8 (YA 19), 9 (YA 20), and 10 (YA 16 & 18) Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. The health, personal and social care needs of residents were set out in individual care plans. Health needs could be improved and reviews need to be in consultation with residents. . Medication procedures could be improved. Residents’ rights to privacy and dignity were not fully respected. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans (Older Persons - OP) and two care plans (Younger Adults YA) were checked and these showed the action that needed to be taken to ensure residents’ needs were met. Risk Assessments were in place. More information was needed to determine the monitoring and action taken following accidents, particularly with older persons. Care plans and risk assessments were reviewed monthly for both older persons and younger adults, however there was no evidence to indicate that residents, especially residents on the Young Physically Disabled Unit (YPD) were consulted about these reviews. This was discussed with the head of the YPD Unit. Medication was checked for the three tracked residents (OP). The medication was in the monitored dosage system and it tallied with the Medication Administration Records sheets. Loose medication (i.e. medication in packets and bottles) was checked for four other residents (OP). Paracetamol 500mg tablets for two of these residents had not been carried forward on the Medication Administration Records sheets; therefore there was no current record of quantities. In the Young Physically Disabled Unit, two residents were asked about their medication. Both stated that the home looked after their medication. The head of this unit confirmed that the home dealt with residents’ medication. The need to encourage and support residents to retain, administer and control their own medication, within a risk management framework, was discussed. Medication that required refrigeration was stored in a refrigerator solely for that purpose, however refrigeration temperatures were not recorded. Controlled drugs were stored properly and the controlled drugs register was completed correctly. Residents had mobility aids to maintain their independence. All persons interviewed were asked about residents’ privacy and dignity. All comments were positive. “They treat her like a grown up – with respect”. However, during one conversation, the resident was asked if she had keys to lock her door and lock her money away. She admitted that she did not have keys. This was discussed with the manager who stated that keys would be provided. Comments were also received about the home’s laundry service and how clothing was damaged, particularly pleated skirts and bra fastenings. During a tour of the building it was noted that a resident who was inappropriately dressed was having her hair done in the lounge/dining room in the dementia unit. This did not respect the resident’s privacy and dignity and was brought to the attention of the manager who agreed to look at alternative sites for hairdressing. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 (YA 11,12 and 14) 13, (YA 13 and 15), 14 (YA 7) and 15 (YA 17) Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents’ lifestyle in the home generally matched their expectations and preferences. They were encouraged to maintain contact with their family, friends and the local community as they wished and had choice and control over their lives. Residents received a wholesome appealing balanced diet with choices at all meals. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 13 EVIDENCE: The home had two activities co-ordinators but only one was seen during the three days of the site visit. Residents were relaxed and some residents on the dementia unit were enjoying craft activities with an activities co-ordinator. Programmes of activities were displayed in the entrance hall and at various points throughout the home. The dementia unit had an activities room where various crafts were displayed and there was a good selection of games. Comments about activities were “Bakes buns, make cards, take her out for little walks”, “Growing some sunflowers”, “Art and pin cushions”, and “Would like more trips”. Two relatives of residents said that although their relatives weren’t capable of joining in activities, they were encouraged to attend the sessions. However, there were some comments that indicated that activities were not available throughout the home and that staff didn’t have time to even chat to residents. These were “Not enough activities to help stimulate stroke patients, most activities seem to be for the more mobile and active residents” and “Activities not organised at all. Be welcome during winter months. Very long days with nothing to do” and “Need a lot more activities and staff able to do more personal things, e.g. manicures, even time to chat. Most of the carers are great but they never have time”. Good interactions between staff and residents were observed on all the units within the home. Residents said that they could choose how to spend their day and their care plans included information on their likes and dislikes including what time each resident liked to get up and go to bed. Residents on the Young Physically Disabled (YPD) unit said that there were enough activities for them to do in the home including a computer room. One of the residents said that he spent a great deal of his time outside the home and was also on a programme for independent living which was co-ordinated by his social worker. This involved being encouraged to do as much for himself as possible. The head of unit said that some residents liked to spend the weekends at home with their families. Residents considered that they had freedom of choice and their rights were respected. Comments by residents were, “Not many restrictions” and “More or less do what you want”. Residents’ views of the meals were mixed. Some thought the food to be good whilst others thought it could improve. Comments were “The food is good”, “Very good” “Alright”, “Food is out of this world”, “Likes all the food – lovely meals”, “Poorest meal is supper”, “Menu would be nice. No alternative provided. Supper is dreadful 9.15 pm, ½ slice bread and marg and 2 biscuits, cup of tea. Our tea time is 4pm, so most are ready for a snack” and “Dinners not as good since other cook left”. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 14 The menus were displayed but were in very small print. The manager said that she was awaiting delivery of new large print versions. Choices were listed on the menus for all meals and the manager said that all residents were asked for their choices. Special diets were catered for including soft diets, liquidised diets, diabetic and gluten free diets. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 (YA 22) and 18 (YA 23) Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents and their families were confident that complaints would be dealt with. Residents were protected from abuse. EVIDENCE: The complaints procedure was displayed but it did not state that complaints would be addressed within 28 days, neither did it give the address and telephone number of the local Commission for Social Care Inspection office. Residents and relatives said that they were confident that their complaints would be listened to and dealt with. Residents said, “Yes, my views are listened to”, “Get on great with the staff” and “I would tell Julie if I wasn’t happy about anything”. One relative said that she had complained and the issue was addressed to her satisfaction. The CSCI had received one anonymous complaint, which was dealt with satisfactorily. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 16 The manager had undertaken training to enable her to train the staff in adult protection. All staff had undertaken this training. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 (YA 24) and 26 (YA 30) Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Residents lived in a safe, well-maintained environment that was clean and generally hygienic. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home was clean, tidy and generally hygienic. There were no offensive odours. Lounges, dining rooms and a sample of bedrooms, bathrooms and lavatories were checked on each unit. Air conditioning had been fitted in the conservatory on the dementia unit, which ensured that the room was a comfortable temperature for residents. A corridor leading from one wing to another wing of the dementia unit had been painted different colours to aid orientation. In the lounge/dining room in the dementia unit, a resident was having her hair done and was surrounded by other residents’ hair cuttings on the carpet. The need for hygienic, easily cleanable flooring to accommodate hairdressing was discussed with the manager. (See also Standard 10 re respect and dignity). Bedrooms were spacious and some had en-suite facilities. All bathrooms and lavatories seen were clean and tidy. A bathroom on the dementia unit was showing signs of wear. The manager said that it had only recently been redecorated but admitted that it was the most frequently used bathroom. The manager also pointed out an area of the home that was due for redecoration. Residents said, “Yes, I like the home”, “Very clean”, “High standard” and “Always nice and clean” Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27(YA 33), 28 (YA 32), 29 (YA 31,34) and 30 (YA 35) Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. The numbers and skill mix of staff did not always meet all residents’ needs. Staff were trained and competent to do their jobs, but the ratio of care staff with NVQs needed to improve. Residents were supported and generally protected by the home’s recruitment practices. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 20 EVIDENCE: Comments about staffing levels were mixed. Some comments were “Yes” there were sufficient staff whilst other comments were “Residents are left in sitting room for long periods without a carer on hand”, “Would like a member of staff in vicinity of lounge when lounge is full because of having to search for staff when some want toilet or are standing up when in danger of falling”, “I don’t think there are enough staff since Four Seasons took over” “Seems short staffed”, “It is sometimes difficult to find someone who is able to handle a query, or has time” and “Staff are nice but not enough of them on each shift”. Four staff files were checked. The relevant information as required by the Care Homes Regulations was included, i.e. application forms, dates of employment and references. Criminal Records Bureau disclosures were kept separate. A new CRB and POVA disclosure had not been obtained for one member of staff who had previously worked at the home and subsequently reemployed. This was discussed with the manager. The Pre-inspection Questionnaire provided information that 46.5 of care staff were qualified to NVQ Level 2 or above, which was below the minimum requirement of 50 . All new staff undertook induction training. The Preinspection Questionnaire provided information that eight of the staff had current first aid certificates and all staff had undertaken a variety of training to ensure they were up to date with current practice. Staff were observed to be calm, friendly and professional in their approach and care practices and this was confirmed in comments made. Comments were “I like the staff….helpful”, “I’ve had no difficulty getting on with them.”, “Wonderful staff”, “Treat me like a normal person”, “Never met friendlier open people”, “I think they look after her very well”, “They’re good with her” and “Staff are friendly” Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 (YA 37), 33 (YA 39), 35 (YA 36) and 38 (YA 42) Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service. Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 22 The manager was fit to be in charge of the home. The home was run in the best interests of residents. Residents’ financial interests were safeguarded. Residents’ health, safety and welfare were promoted. EVIDENCE: The registered manager was a good role model for staff. She had attained the Registered Managers Award and kept up to date with current practice. At the time of the site visit, she and the head of the dementia unit were to attend a Dementia Mapping course to increase their knowledge of people with dementia. Comments about the manager were positive and included “Approachable, flexible and gives advice” During the site visit a representative for the registered owners visited the home for a meeting with the manager. The manager explained that the meeting was to discuss new auditing systems that were being implemented as part of the home’s quality assurance system. The manager said that the quality assurance programme included care plans, cleaning rotas, complaints, bed rails, maintenance, accident reports and staff issues. Residents and Families meetings were held. The home produced a newsletter and the registered owners also produced a newsletter. The registered owners representative visited the home and produced reports as required by Regulation 26 of the Care Standards Regulations. The home had safe storage facilities for money held on behalf of residents. Receipts were issued for money held by the home. All money was banked in a Trust Account with no interest paid but no charges incurred. Bank statements were kept. Records were kept of each resident’s individual finances and receipts were kept for purchases made on behalf of residents. The manager and senior staff ensured that all staff were up to date with training to promote safe working practices. All training was monitored and on a rolling programme. Staff said that they had attended many courses within the last year. Fourteen staff were due to attend Infection Control training. Fire drills were held regularly. Fire alarm tests were carried out weekly. The Pre-Inspection Questionnaire provided information on the dates that systems and equipment had been serviced and maintained. Cherry Trees Care Centre DS0000066494.V308140.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 3 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Cherry Trees Care Centre DS0000066494.V308140.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. 1 Standard YA6 OP7 Regulation 15 Requirement Timescale for action their 13/11/06 be plan 13/11/06 2 OP8 15 3 YA20 OP9 12 4 OP9 13 5 6 7 8 OP10 OP12 OP15 OP16 YA22 12 16 12 22 Residents (or representatives) must consulted about care reviews. Records of the care given must include information of how residents are monitored and the action taken following accidents. Residents must be encouraged and supported to retain, administer and control their own medication within a risk management framework Staff who deal with medication must ensure that the correct recording procedures for medicines are adhered to. Residents must be treated with respect and dignity at all times. The programme of activities must be made available to all residents. Residents must be made aware of the meals and choices on offer The complaints procedure must include the contact details of the local office of Commission for Social Care Inspection. information DS0000066494.V308140.R01.S.doc 13/11/06 16/10/06 16/10/06 13/11/06 16/10/06 16/10/06 Cherry Trees Care Centre Version 5.2 Page 25 9 10 OP19 OP26 16 11 12 13 OP27 OP28 YA32 OP29 YA34 The identified bathroom on the dementia unit must be redecorated. 12, 16, 23 An alternative site, (that promotes residents’ rights to privacy and dignity) with easily cleanable flooring must be used for hairdressing in the dementia unit. 18 Staffing levels must be appropriate to residents’ needs. 18 A minimum ratio of 50 trained members of care staff (NVQ 2 in care) must be achieved. 19 All staff including re-employed staff must undertake CRB and POVA disclosures prior to employment. 16/10/06 16/10/06 16/10/06 11/12/06 16/10/06 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 OP33 Good Practice Recommendations Residents should be consulted about the meals particularly the supper Cherry Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Trees Care Centre DS0000066494.V308140.R01.S.doc Version 5.2 Page 27 - 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. 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