Inspection on 16/05/07 for Cherrytrees

This inspection was carried out on 16th May 2007.

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

The inspector 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

Cherrytrees 27/02/06

Cherrytrees 12/07/05

Cherrytrees 01/12/04

Cherrytrees 20/05/04

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

CARE HOME ADULTS 18-65 Cherrytrees Cherrygrove Road Frome Somerset BA11 Lead Inspector Pippa Greed Unannounced Inspection 16th May 2007 09:00 Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherrytrees Address Cherrygrove Road Frome Somerset BA11 01373 452965 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) Somerset County Council (LD Services) Shirley Perry Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users may be admitted who have concurrent physical disabilities and/or sensory impairment Service Users will be admitted for a maximum of 3 months between each admission and discharge 15th June 2006 Date of last inspection Brief Description of the Service: Cherrytrees has been registered as a care home for up to 6 younger adults (aged 18 - 65) with learning disabilities for respite care since September 2003. Also run from the same site is a community care outreach service for adults with learning disabilities. A number of local people also access the home for day care services. The home is run by Somerset County Council. A registered manager is in charge of the day-to-day running of the home. Cherrytrees is a single storey purpose built home in the town of Frome. This has the local facilities of shops, banks, pubs and leisure amenities. Cherrytrees is adapted to be able to support highly dependent service users whilst maintaining a homely atmosphere. All accommodation is in single rooms. Outdoor space includes well-maintained gardens as well as shared use of an all-weather outdoor sports court. The home benefit from being sited adjacent to a day service facility for adults with learning disabilities, also run by the Council. The current charges are £51.00 (18-24 years), £63.00 (25-59 years) and £98.00 (60 years) per week. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection was conducted over one day (7.5hrs) by CSCI Regulation Inspector Pippa Greed. On the day of the inspection, three support workers, two community care assistants and the manager were on duty. Two support workers and two community care assistants were on duty during the afternoon. One of which was rostered to do sleep in duty that evening. The registered manager was available to assist the inspector during the unannounced visit. On the day of the inspection three service users were participating in a short shopping trip. One service user left to attend craft session at the day care centre next door known as the Frome Enterprise Centre. Two community care assistants supported two service users who live in the community with their personal care and weekly shopping. One service user at home chose when to get up and which recreational activity to carry out. The atmosphere was purposeful and welcoming. Staff were seen to work in a supportive manner with the service users. The inspector viewed all communal areas and four service users bedrooms with their expressed consent. The inspector met with six service users at the day centre, engaged with one service user and spoke with three service users. The inspector also observed daily routines within the home. The inspector met with two staff members to discuss their induction, supervision and training provision. The staff commented that they felt supported by the manager and enjoy working in the home. A selection of records was examined. These included three service users care plan and three staff recruitment files. CSCI sent out feedback cards for five service users, six staff, and three relatives. No service user’s surveys were received. Four care staff comment cards were received and confirmed that they are aware of organisational policies and receive regular supervision. One staff member wrote ‘It is a lovely place to work’ and ‘Service users always look forward to their stays at Cherrytrees. This information has come from carers and people who work at the day centre.’ One survey was received from a relative who advocated on behalf of the service user. The relative wrote ‘He appears to enjoy his time at Cherrytrees. (Service user) looks forward to going and will look for his suitcase on the days he goes. He is equally happy to return home to me.’ The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Cherrytrees DS0000054215.V335450.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: 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. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and their families are provided with the information they need to enable them to make an informed choice about moving to the respite unit. Appropriate assessments are completed to ensure that the home will be able to meet service users’ needs. EVIDENCE: Prospective service users are assessed prior to admission to ensure that the home is a suitable placement. The home provides a service for respite care and day service users. Assessments are also obtained from other health care professionals where appropriate. Prospective service users are encouraged to visit the home prior to making a decision about moving to the home. This would be for at least half a day followed by an overnight stay. Exceptions to this would be tailored to meet the individual service users needs. The manager of the home will use the information from the Community Care Assessment to decide on the frequency of stays, following consultations. A comprehensive assessment was sampled in one care plan for a prospective service user. This was completed in detail and signed by the service user. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 9 A relative wrote ‘My son was introduced to the new unit by Day Care staff and social worker. I went to the unit to have a look around.’ The relative confirmed they received a booklet about the home. The Statement of Purpose would benefit from a more user-friendly approach such as use of pictorial symbols and photographs to make this more accessible for the service user. The language used was simple and accessible. This could be improved further with use of Somerset Total Communication commonly used within the Somerset County Council network. A contract is available for each service user. This is an agreement between the service user and the home. The contract sets out the terms and conditions, rights and responsibilities of both parties. This includes a written agreement on confidentiality setting out the principles governing the sharing of information including the arrangements for visitors. Where a service user is unable to enter into such an agreement, a relative or advocate may act on their behalf. Many of the service users access the home for few days very regularly and their needs are well known by the home’s team. Cases are also discussed with the area’s team leader during monthly visits. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a detailed and well-written care plan for each service user. Service users are encouraged to exercise choice and participate in all aspects of life within the home. Service users are supported in taking risks. Records relating to service users are stored securely and appropriately maintained. EVIDENCE: The inspector sampled three service users care plans. Care plans are well maintained for each service user. Care plans included a photograph of the service user, and provided information regarding service users needs, daily routines and preferences. The care plans also included records of visits to health care professionals and contact with families. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 11 The care plans covered the following areas: -personal profile, service users involvement in care planning, service user’s likes and dislikes, service users preferred mode of communication, mobility, services agreed, important relationships, personal care guidance, eating and drinking guidance, health and medical, community inclusion (college), money and finance. Individual risk assessments had been completed for each service user. Service users review meetings are held regularly and service users are encouraged to attend where possible. A relative wrote regarding making decisions - ‘My son uses some Total Communication symbols and gestures to communicate’. Service users are encouraged to exercise choice. This is done through individual communication system. There is a new staff duty board with photographs, which shows service users who is working that day. The home has implemented laminated cards with pictorial symbols to demonstrate where the activities cupboard is, where the toilet is and where the locked chemical storage cupboard is. These signs will enable the service users either new or regular visitors to know and understand what is kept behind those doors. These were recommendations from the last inspection. The home keeps individual day to day records that detail the activities and choices that have been made by service users. One service user showed the inspector his bedroom. He was particularly proud of his photograph displayed on his bedroom door, which gave him a sense of pride and belonging. Financial records were seen for one service user and these were correct. Two staff signatures supported all entries including details of transaction, amount received, spent and final balance. The home has installed a fixed lockable safe in each service users wardrobe to enable service users to store medication and personal monies. This was a requirement from the last inspection and has been met. All records relating to service users are stored securely, and may be accessed by service users at their request. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home offers service users opportunities to engage with peers, access appropriate leisure activities, and exercise choice. Service users are supported with friendship and family contact. Service users rights and responsibilities are respected. Service users are offered a choice of menu, and the options are developed around their preferences and dietary needs. EVIDENCE: On the day of the inspection, service users were accessing a range of activities, some of which were daily living skills, weekly shopping, café visit, lunch preparation, and session at Frome Enterprise Day Centre. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 13 Some examples of activities provided by the home such as use of all weather sports court, and trips out to art exhibition, Horseworld, Longleat and local beaches. Day centre offer a range of session such as rambling, drumming, homeskills, music, road safety, story telling, cooking, and gardening. Service users accessing the day centre also participate in work preparation such as making picture frames and recycling old furniture. Service users also access the local community, visit local shops, pubs, restaurants, local parks, cinema and social club (Gateway Club). They are able to pursue their personal hobbies and interest in the home. In-House activities include painting, crafts, puzzles, Playstation, videos, music, games, cookery session and sports. A service user was observed carrying out a daily living task. Through the interaction and communication, it was evident that staff are well motivated and clearly understood the service users needs. Service users were supported with decision-making and encouraged to do so. Service users were also empowered to walk around freely, make phone call when they wished and ask staff for support when required. This promotes good practice in equality. The manager informed the inspector that holidays and short breaks were arranged at Cherrytrees. A service user who lives in the community was supported by staff to take a week’s holiday in Cyprus in July 2006. Two service users enjoyed a short break to Paignton, Devon for four days in September 2006. Two service users went to a self-catering cottage in Dorset for a long weekend in July 2006. The inspector noted that the lunchtime routine was relaxed and unhurried. The meal prepared appeared appetising. Cooked roast chicken with salad. The home has a pleasant dining room that was comfortable to eat in. Service users were enabled to make drinks or choose a snack when they wished. The staff team offer service user choices in all aspects of food and drink and are very aware of the likes and dislikes of the service users. Food monitoring system are in place where needed. The home has implemented a running record to evidence what the service users have eaten for their meals. One service user spoken with confirmed that staff provide mealtime choices and the service user stated that staff give them variety and encourage them to help with cooking. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate assistance to meet their personal care needs. The home supports service users in accessing healthcare services. Service users are protected by arrangements in the home for managing medication. EVIDENCE: The home has appropriate aids and equipment to support service users mobility. The health and safety checks for these equipments are maintained regularly. Through discussion with staff and manager, it was evident that care was taken to check equipment for wear and tear and action where appropriate. It was evident from the care plans through regular monitoring that any changes in the service users wellbeing or behaviour would be identified. The manager and staff team would then take pro-active steps to address and meet changing needs. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 15 The care plans sampled contained health and medical information. Records are kept of all visits and consultations. The home’s procedures for the management and administration of medication were examined at this inspection. Medication was seen to be handled and stored appropriately. The Medication Administration Record clearly demonstrated that two staff signatures confirm all administration. The home has a detailed medication policy in place including homely remedy guidance. Photographs of service users are pre-printed onto their medication administration record to ensure correct medication is given. The home maintains records of medication entering and leaving the home. Two members of staff also sign these. The home has a policy in place in respect of standard 21. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a clear Adult Protection policy, which is accessible. The home has systems in place to protect the service users from abuse. The home has a complaints procedure and policy relating to the Protection of Vulnerable Adults. EVIDENCE: The home has appropriate policies relating to the Protection of Vulnerable Adults, Whistle Blowing, Complaints policy, and Grievance policy. The home’s Statement of Purpose demonstrates to the reader that they can contact the Commission for Social Care Inspection at any stage of a complaint. Two service users spoken with felt confident in raising concerns or complaint with the manager. The inspector met with two staff members and asked about their understanding of Safeguarding Adult procedures. Staff had knowledge of the policy and who to report to. One staff is covering this subject as part of their National Vocational Qualification (NVQ) in care. Staff recruitment files were seen to be robust and contained records required in Schedule 2, Care Homes Regulations. Essential checks such as Criminal Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 17 Records Bureau (CRB) and identification are provided in all staff files. However, written references are kept centrally for long serving staff members. The inspector was informed that there has been one complaint since the last inspection and no complaints/concerns have been raised directly with the CSCI. The minor complaint received by the home was addressed in a courteous manner. Details are recorded appropriately in the home’s complaint log. The home maintains a Concerns, Complaints and Compliment file which evidences correspondences received from families expressing their appreciation and satisfaction with care provided at Cherrytrees. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has been decorated and furnished to a good standard. Appropriate adaptations have been provided. The home has sufficient communal areas and bathrooms to meet service users’ needs. The home was found to have a high standard of cleanliness. EVIDENCE: The home is a purpose built unit that opened in 2003. The home is adapted to a high standard to meet the range of disabilities that service users may have. A tour of the building was conducted during the inspection. All areas are homely and comfortable. All the bedrooms are for single occupancy with en-suite facilities. One service user’s bedroom was viewed with Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 19 permission. The bedrooms viewed were found to be personalised and comfortable. Some of the bedrooms seen were equipped with television and internal telephone system for early morning ‘wake up’ call should the service user wish to be woken up at a set time. Some bedrooms were equipped with overhead hoist track including the ensuite to aid personal care if required. All rooms that were inspected had window restrictor in place and secured wardrobe. There are 9 toilets in this home with adequate space for wheelchair users. There is one very large shared bathroom with a bath suitable for service users with severe mobility impairment to access via an overhead hoist. The water temperature of the bath is displayed on a digital readout. There is also a shower trolley available, where adequate space is provided for its use in the bathroom. All washing and bathing facilities inspected were clean and tidy. Also, paper towels and liquid soap were available. Water temperatures were checked monthly. Communal space at the home includes a large lounge and a separate dining area. The lounge is comfortable and homely. The home has a fish tank with several goldfishes. The kitchen is spacious and provides good storage and cooking facilities. Staff wear catering aprons and hats for improved food hygiene practice. The manager is presently seeking quotes for redecoration programme at Cherrytrees. Funding has been agreed for communal areas to be repainted and lounge furniture to be replaced. There are two patio areas to the rear of the building that are wheelchair accessible and equipped with tables and benches. The surrounding gardens are pleasant and well maintained. The home has shared access of an outdoor sports court. The home also has access to the neighbouring day unit during evenings and weekend if required. The laundry provides good equipment for washing of clothes and machines enable programmes to heat to a degree to manage infection control measures. All chemicals are stored in a locked cupboard. The manager confirmed that yellow waste disposals are stored in secured refuse bin area outside. A quiet room is available for service users and visitors to meet in private. Staff members on sleep-in duties have a bedroom and rest area provided with an en-suite facility. Pictorial signs were evident throughout the home to signpost fire exit or toilets. The home was maintained in a clean and tidy condition. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are experienced and provide a good standard of care. Staffing levels are appropriate to meet service users’ needs. Staff have received Adult Protection training. Staff receive appropriate support and supervision. EVIDENCE: Duty rotas are well maintained. On the day of the inspection, there were three support workers, two community care assistants on duty during the morning, and one manager during the day, two support workers and two community care assistants during the afternoon with one sleep in staff at night. Since the last inspection, two staff have joined the team at Cherrytrees. The Manager has completed an improved training matrix of staff mandatory training needs to ensure that all staff are provided with appropriate training to undertake their role. Newly employed staff complete a thorough Induction programme and undertake National Vocational Qualification (NVQ) training. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 21 Staff are provided with regular opportunities to receive training, and have attended courses on Food Hygiene, First Aid, Fire Safety, Manual Handling and Breakaway. Additional training are provided such as Health & Safety, PIT, Mental Capacity, PMLD, Dementia, Medication, Equality & Diversity and PRAD. A few staff members will need food hygiene refresher and the home has taken steps to nominate and arrange for updates. Out of the nineteen staff employed, nine have obtained the NVQ level 2 qualification in care. A further three staff are currently undertaking NVQ. Three staff recruitment files were examined. These were maintained appropriately. Each was found to contain the documentation required within Schedule 2 of the Care Home Regulations 2001. Please refer to Concerns, Complaints and Protection section for more details. The inspector viewed the records in relation to staff supervisions and appraisals. The inspector noted that staff has been supervised regularly and recently. Two staff members were spoken with and both confirmed that regular communication takes place within the home. One staff said ‘I like the variety and enjoy working here.’ Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well run and benefits from a competent manager. There is a calm and purposeful atmosphere within the home. Health and Safety checks are well maintained and the service users welfare is protected. EVIDENCE: Sam Perry is the Registered Manager for the home. She has many years experience of providing care to a service users who have a learning disability. Sam has worked at Cherrytrees since it opened with the exception of one-year secondment to Adult Placement. Sam has attained the City & Guilds Advanced Management in Care. She is also a registered nurse. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 23 Staff at the home seek service users’ views on an individual basis, taking account of behaviours, verbal and non-verbal communication. There is a strong person centred focus and this was evident throughout the inspection process. Staff spoken with confirmed that the manager was approachable and that they would be able to raise any concerns. The staff spoken with commented that they felt well supported. The home has appropriate policies and procedures in place to safeguard vulnerable service users. All records relating to service users are stored securely in accordance with the Data Protection Act 1998. The home has a current Employers Liability insurance cover. The home operates a comprehensive system of health and safety audits. Fire safety records were examined and checks were carried out on 16.5.07. Fire equipment had been serviced and tested as required. The electrical hardwiring certificate and landlord gas safety certificates have been appropriately maintained. Staff on a monthly basis carries out bed, slings and hoist visual checks. Lifting Operations, Lifting Equipment Regulation (LOLER) tests were carried out on 3.5.07 and ARJO were checked on 13.4.07. Records are kept of hot water temperatures and maintained appropriately. This was last checked on 4.4.07. Accident and Incident log was sampled and the last entry was March 2007. Each service user’s incident form is stored in their care plan file in line with Data Protection Act. The manager informed the inspector some examples of quality assurance monitoring. These are offered through monthly visits (regulation 26), staff meeting, newsletters and service user’s annual review. The inspector saw records of daily fridge and freezer temperatures. These were found to be within safe range. Food probe records were seen and were maintained within appropriate range. Food opened were clearly labelled and dated. The kitchen was maintained in a good hygienic condition and state of repair. The home has a Hazard Analysis Critical Control Policy in place and cleaning schedules were also seen. Safeguards are in place for good food hygiene safety. Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 4 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 3 3 3 3 4 3 Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 25 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. Refer to Standard Good Practice Recommendations Cherrytrees DS0000054215.V335450.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Cherrytrees DS0000054215.V335450.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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