Inspection on 30/01/09 for Cherrytrees

This inspection was carried out on 30th January 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherrytrees 23/05/07

Cherrytrees 08/06/06

Cherrytrees 12/12/05

Cherrytrees 31/05/05

Cherrytrees 25/10/04

Cherrytrees 18/05/04

Cherrytrees 05/12/03

Similar services:

Coopers Mill Ltd

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Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Cherrytrees Cherrytrees Kitelands Road Biggleswade Bedfordshire SG18 8NX Lead Inspector Nicky Hone Key Unannounced Inspection 30th January 2009 12:45 Cherrytrees DS0000033114.V373986.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 DS0000033114.V373986.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 DS0000033114.V373986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherrytrees Address Cherrytrees Kitelands Road Biggleswade Bedfordshire SG18 8NX 01767 313370 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) Bedfordshire County Council Manager post vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Maximum number of service users: 2 Gender: Male & Female Age Range: 18 -65 Category: Learning disability (LD) Period of stay: Respite only - up to a maximum of 6 weeks Until the reprovision of this service takes place, the premises must be safe, and meet service users` individual and collective needs 23 May 2007 Date of last inspection Brief Description of the Service: Cherrytrees is a respite care service located on the outskirts of Biggleswade. The building and grounds are owned and maintained by Aldwyck Housing Association, with Bedfordshire County Council providing the staffing and care support. The long-term plan for this service is reprovision. This is because the building does not meet the National Minimum Standards (NMS) for Younger Adults (18-65). It is hoped that the service will remain in the local area, but at the time of this inspection, there were still no definite timescales for this to take place. The accommodation comprises of a small flat, which is intended to provide respite care for up to 2 adults with learning disabilities at any one time. Stays are limited to a maximum of six weeks. There are two bedrooms, a shared kitchen, a bathroom and a living/dining area. The accommodation would not meet the needs of individuals with a severe physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. Cherrytrees DS0000033114.V373986.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 2 star. This means the people who use this service experience good quality outcomes. For this inspection we (the Commission for Social Care Inspection) looked at all the information that we have received, or asked for, since the last key inspection of Cherrytrees. This included: - The AQAA (Annual Quality Assurance Assessment). The manager had sent us a completed AQAA in January 2008. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live and stay here. The AQAA also gives us some numerical information about the service; - Surveys which we sent to the home to give to people who live and stay there, their relatives/carers and to staff. We received 2 replies; - What the service has told us about things that have happened in the home. These are called notifications and are a legal requirement; - Any safeguarding issues that have arisen; and - Information we asked the home to send us following our visit. This inspection of Cherrytrees also included a visit to the home on 30/01/09. We spent time talking to the manager, area manager and the staff on duty. We looked round the home and spent time observing what happened when people arrived from their day services. We also looked at some of the paperwork the home has to keep including care plans, risk assessments, medication charts, and records such as staff personnel files, staff rotas, menus and fire alarm test records. What the service does well: We were impressed with this service. The manager and staff team are working hard to give the best possible service they can to each of the people who stays here. Everything about this service that the manager and staff have control over was good or moving towards being excellent. One of the people staying at the home said “Staff are really nice, I really like being here”, and we saw several compliments on the notice board, including “I like coming to Cherrytrees to see my friends”, and “I like the respite unit because the staff Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 6 are pleasant and nice and kind”. A relative we spoke with said “The staff are so friendly and bubbly – it’s brilliant. I can’t fault them at all so far”. A relative who returned our survey wrote “He enjoys his stay and seems quite happy”. The staff we spoke with clearly love the job they do, and the manager is enthusiastic, supportive and working extremely hard in the short time she has available to make this an excellent service. The people staying at the home on the day we visited were clearly comfortable and happy to be here. They both had good, friendly relationships with staff, who clearly cared about doing the best they can for the people they support. Information about the home is available, written in a way that most people can understand. Detailed and thorough assessments of peoples needs are carried out before people start to use the service, and support plans are written in a person-centred way and give staff good, detailed guidance on how the person wishes to be supported. Risk assessments are being written in a way that people can understand. People continue to attend their day services during the week, and are offered some opportunities for leisure activities during the evening and at weekends. A varied, nutritious diet is offered and people are encouraged to practice their skills in the kitchen by helping to prepare meals. People know their complaints will be listened to, and that staff have been trained in safeguarding so that they will be kept safe from harm. Peoples money is handled well. The staff team has been recruited well, receive all the training needed to do their jobs well, and receive regular supervision and an annual appraisal. The home checks that it is offering what the people who stay there want, in a number of ways, including sending people questionnaires, and asking people to say if they have enjoyed their stay and how it could be improved. Records are kept as required. What has improved since the last inspection? Following our last inspection we made 9 requirements, only one of which was not fully met. During the inspection the manager summarised some of the improvements made in the past year. These include: support plans are now more service user friendlyand more customer focussed; staff have received a lot of training; the range of visual aids to assist people to make choices has increased; and the service is starting to focus on independence skills training. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 7 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 DS0000033114.V373986.R01.S.doc Version 5.2 Page 8 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 DS0000033114.V373986.R01.S.doc Version 5.2 Page 9 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 People who use this service experience excellent quality outcomes in this area. Good information is available about the service for people thinking about staying here, and thorough assessments are carried out so that people know the home can meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Cherrytrees respite service has a Statement of Purpose, and a Service User Guide (SUG). The SUG is available in an easy-read format, with photographs and symbols. One of the people staying at Cherrytrees on the evening we visited was new to the service and this was his first weekend stay. Records showed that the home is very thorough in collecting all the information staff will need so that they can support each person properly. When she receives a referral (which includes a full assessment done by the person’s care manager/social worker), the manager goes to meet the person at home, and speaks to any other services involved in the person’s support (for example, day services, A&R team). She completes a personal profile/assessment, as well as any risk Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 10 assessments, care plan, and any guidelines needed for staff, for example management of a persons epilepsy. This was all in place on the files we looked at. Everyone new to the service undergoes a ‘transition’ period. This is designed to meet each individual’s needs. The person we met had come to Cherrytrees for tea on 2 occasions, and the third time had stayed overnight. It had gone well so he and his parents had decided he would be happy to stay for the weekend. Full contact details for his parents were on file just in case he needed them during the weekend. Each person also agrees a contract with the home. This has been designed in an easy-read way, with photographs and large print, and each person (or their representative) has signed their contract. Cherrytrees also has a separate part of the contract, explaining that there is only one bathroom in the home, and asking people to agree to share with the other person. Cherrytrees is quite a small building, so is not suitable for people with severe physical disabilities. Most of the time there is only one member of staff with the two people staying here, so staff are careful about which two people are staying at the same time, for example, it would be difficult to offer a good service if both people need a lot of personal care, as there would be less time for activities and so on. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 11 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 People who use this service experience good quality outcomes in this area. People have been involved in their support plans which are clear and detailed, and give staff good guidance on the way each person wants to be supported. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each person who stays at Cherrytrees has a detailed support plan in place, covering all aspects of their life. We looked at the information held about three people. The paperwork is very neat and well-organised, so it is easy for staff to find the information they need. Each person has a ‘personal profile’ which picks out the most important points about the person and the support they need. An alert page is placed at the front of each file so that essential information, for example if the person has any allergies, or has epileptic seizures, is immediately obvious. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 12 The personal profile contains a lot of information, from which care plans are developed and added to/altered as people get to know the person. We saw that one person’s care plan had been reviewed and updated every six months. A ‘diversity profile’ is completed with each person, and risk assessments become more personalised as staff get to know each person. Staff write in daily records at least three times a day, which gives a clear, detailed picture of how each person has spent their day. The manager said she is working with the speech and language therapist to develop a communication system for each individual, which includes communication passports, timetables and so on, using pictures and symbols with Velcro. On one file we saw a risk assessment about whether the person wanted a key to their room. This had been drawn up using pictures and easy language. The manager said further risk assessments were being developed in this format so that people could understand about the risks, and perhaps understand why any limitations had to be put in place. Staff from Cherrytrees are involved in the annual review which social services carries out to make sure the support being provided meets the person’s needs. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 13 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 People who use this service experience adequate quality outcomes in this area. Staff are working hard to increase peoples skills so they can be more independent, but people staying at Cherrytrees do not have enough opportunities for activities to make their stay interesting and fun. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff at Cherrytrees have started to introduce a ‘supporting people’ program for people coming for respite stays. ‘My supported living targets’ looks at what each person would like to achieve and gives them some goals, mainly around household chores, to work towards. This is done using pictures and symbols, and written in a person-centred way using “I”. When people carry out a task included in their targets, they are assessed and their progress is evaluated. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 14 The evaluation is produced in the form of a coloured pie chart every six months which shows clearly how they are getting on. Before people are due to arrive for their stay, staff send them a ‘planning your stay’ document which some people will complete at home and bring in with them. Others prefer staff to complete it with them when they arrive. This gives people the opportunity to say what they would like to do during their stay. People are also encouraged to complete a reviewing your stay document when they leave, to look at whether they were able to stick to the plan, and how much they enjoyed what they did during their time at the home. This is then used to try and make their next stay even better. People who want to can take a copy home so their family know what they have been doing. The manager is putting together a list of the cost of any activities that people might be interested in. She showed this to us, and the main cost is for transport – taxis if the weather is poor, or local buses/trains cannot be used. She said some families feel they cannot afford some of the activities. The home would be able to offer a better service if there was a car that staff could use to take people out in. We looked at the records of the activities that people have been involved in during their stay. The weekend before our inspection, one person had gone out with his dad on the Saturday. The second person did not go out at all for the whole weekend: the manager was not sure whether this was the person’s choice. On one weekend staff had recorded that one person had planned to go shopping but could not “as the other client was poorly”. Neither person had been out all weekend. Generally records showed that people are not able to go out as often as they might like to because there are not enough staff. People choose what they would like to eat, when they arrive. Some people choose to go back out and shop for what they would like to eat, others prefer to choose from food that is already in the home’s freezer. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use this service experience good quality outcomes in this area. People are supported with their personal care in the way they prefer, any health needs during their stay are met and staff administer medicines correctly and safely. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Peoples support plans contain details of the support they need while staying at the home, including with their personal care, and the ways in which they like to be supported. As this is a respite service, peoples main carers retain responsibility for all medical issues. However, the home gathers as much information as possible about peoples health and will seek medical advice if needed during the persons stay. The staff will also support people to attend any medical appointments that fall during their stay, if their carers are not available, and deal with any emergencies such as broken glasses. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 16 There is an alert page, now in the front of each persons file, which highlights any medical issues that staff might need to be immediately aware of, such as allergies, and conditions such as epilepsy or diabetes. Staff assist people with their medication if needed, and each person has a contract in the medication file which they, or their representative, have signed to say they are happy for staff to administer their medicines. Medication is kept in a locked cupboard in the office. The medication file includes a photograph of the person, and there is an explanation of how each person likes to take their medication. We looked at one Medication Administration Record (MAR) chart: the medicines had been booked in and out, and the chart had been completed properly. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use this service experience good quality outcomes in this area. People can be confident that their concerns will be listened to and acted on, and that staff are trained to keep them safe from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A pictorial complaints procedure has been developed which is easy to understand for the people who stay here. It is displayed on a ‘complaints board’ and on the notice board, in the hallway. The home keeps a record of any complaints. This showed that no complaints have been received since our last inspection. The home does not deal with peoples finances at all. People bring small amounts of cash with them to pay for activities they have chosen to do. There is a record on each person’s file, stating whether the person wishes to keep the money themselves, or put it in the office safe. The manager is developing a list of costs for each activity so people know how much to bring in. All the staff who work at Cherrytrees have been trained in safeguarding vulnerable adults (SOVA). The procedure for staff to follow, and telephone numbers for them to contact the right people if they suspect any abuse is happening, are clearly on display in the office. No SOVA referrals have been made. Cherrytrees DS0000033114.V373986.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, 27, 28, 30 People who use this service experience good quality outcomes in this area. Cherrytrees is not ideal for its purpose, but recent decoration has made it a comfortable, homely and clean place to stay. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Cherrytrees respite service is a small flat attached to a larger building which used to be a residential care home but is now supported living. The flat has its own front door, which is through a fenced, paved courtyard area which is not very attractive or welcoming. The hallway is quite narrow, goes past the bedrooms, office and bathroom, and leads to the lounge/dining room. The kitchen is off the dining area. Bedrooms do not have washbasins or ensuite facilities. Although very small, staff have tried to make the best use of the space available and it feels homely and welcoming. Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 19 The lounge/dining room had recently been decorated and refurbished, and now offers people a very modern, clean, yet homely, room to be in. The bathroom had also been completely re-done, and now has a walk-in shower and a bright, clean feel. There is only one toilet, which staff said could cause difficulties if someone is enjoying a nice long shower and someone else needs the toilet. Without a wash basin in the bedroom, people are not even able to clean their teeth if someone else is in the toilet. This is also the only toilet for the staff. Staff had recognised this potential problem, and each person has signed a contract to say they agree to share. The relative we spoke with said, “the place is decorated nicely and always looks so nice”. Cherrytrees DS0000033114.V373986.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): 32, 33, 34, 35, 36 People who use this service experience adequate quality outcomes in this area. The people who live here benefit from staff that are recruited well, and who have sufficient training, supervision and support so that they can do their jobs properly. However, there are not always enough staff on duty to make sure people who stay here have the best possible experience. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Usually, there is only one member of staff on duty for the two people staying, with a manager on call. Extra staff come in, for example if a new person is coming for a tea visit. There is always a manager on call on the end of the telephone, or available to come in if needed, and in a real emergency there are always staff in the supported living unit next door. We looked at the information kept in the home about three of the staff. The information was all up to date and very well organised. There is a pro-forma in place for each staff member, including agency staff. Each has a photograph of Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 21 the staff member, and the ones for the homes own staff show that all the information required by the regulations is on their personnel file, held centrally at County Hall. These had been verified by a senior manager. We spent a morning in June 2008 checking a random selection of files of staff who work across the County Councils registered services. Generally all the required information was available on the files we looked at. Some staff have been employed for many years, and started long before the current requirements were in place. The Council has worked hard to get as much information as possible, and has ensured, for example, that Criminal Record Bureau (CRB) checks have been done, and are renewed every three years. Records showed that all staff have received all ‘mandatory’ training (that is fire safety; moving and handling; infection control; food hygiene; safeguarding; and first aid), as well as a range of other training. One staff member we spoke with told us she is currently undertaking an LDQ (Learning Disability Qualification). Training for staff in the administration of medication is very thorough. Staff take two external courses and then the manager has devised a competency record and questionnaire. Each staff member is observed until they are deemed to be competent. All staff, including the regular agency staff, receive supervision, annual reviews take place and all staff have been given a copy of the updated staff handbook. Staff meetings are held monthly and minutes kept. The staff member we spoke with confirmed everything the manager said, for example about supervision, induction, training, staff meetings and so on. She said, “I love it – I’m always here”. Cherrytrees DS0000033114.V373986.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 People who use this service experience good quality outcomes in this area. This home is managed very well indeed, so that the people who stay here have the best possible experience, based on what they want to do. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager, Lindsay Scott, manages the domiciliary care agency which supports the people who live in the supported living scheme next door. He has handed over the management of the respite service to Charlotte Bond who is now the person managing the respite service, and the manager who assisted us with the inspection. She has been acting manager for some time, and told us she will be applying to CSCI for registration. Ms Bond has Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 23 completed the Registered Manager Award, has an NVQ (National Vocational Qualification) level 4 in Management and a BTech in Social care, so is well qualified to manage this service. However, Ms Bond only works part time (18.5 hours a week), some of which she spends as an assistant manager in the supported living service. The manager explained that because there are only 2 people staying at any one time, this is looked on as a small service which needs far less management time. However, there are currently 17 people receiving a service (and 5 new referrals), so there is a lot of work to do in planning the stays and making sure each person has all the necessary paperwork in place and up to date, as well as doing the 101 other jobs which fall to the manager. It is not acceptable for the manager of a service to have so little time to carry out their role. We were amazed that the manager and the small staff team have achieved so much in the time they have available. The manager is very enthusiastic about what has been achieved already, and how much more can be done to improve the service for the people who stay at Cherrytrees. A number of the things we have talked about in this report, such as the planning and reviewing your stay documents and the support plans discussed and written with people who stay here, all form part of the homes quality assurance system. People who stay are asked for their views on how the service they get could be improved, and the staff team works out how any possible improvements can be made. At Christmas 2008 the home sent questionnaires to all the people who use the service, and their relatives. From the responses they received, a report was written, and any comments acted on. The manager or the person’s keyworker will be visiting each family that wants them to, to discuss what has gone well for their relative and what could be improved. We looked at some more of the records the home is required to keep. A representative of the provider carries out a visit to the service every month and writes a report. The visit, and the resulting report, are very thorough, and highlight any areas in which the service can improve. The manager has devised an action plan to make sure the comments are addressed. The home notifies CSCI of any incidents that affect the well-being of the people staying at the home. The home has a comprehensive fire risk assessment. We looked at records of tests of the fire alarm system and the emergency lighting. The records showed that tests have been carried out as required. The manager explained that if there are people in the building when the alarm is tested, a full evacuation is carried out. Cherrytrees DS0000033114.V373986.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 4 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 2 25 X 26 X 27 3 28 4 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 4 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 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 4 3 3 3 2 X Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA14 Regulation 16(2)(m) and (n) Requirement People staying at the home must be offered a greater range of opportunities for activities and leisure pursuits outside the home. This was a requirement following our previous inspection and has not been met. There must be enough staff on duty at all times to meet people’s needs, including their needs for activity outside the home. The manager must be given sufficient time to spend in the home to make sure s/he is in full day-to-day control. Timescale for action 30/04/09 2 YA33 18(1)(a) 30/04/09 3 YA37 9 30/04/09 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 DS0000033114.V373986.R01.S.doc Version 5.2 Page 26 Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000033114.V373986.R01.S.doc Version 5.2 Page 28 Cherrytrees DS0000033114.V373986.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!