Inspection on 08/06/06 for Cherrytrees

This inspection was carried out on 8th June 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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherrytrees 30/01/09

Cherrytrees 23/05/07

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

Bramley Avenue (73)

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 23/11/2008.

CARE HOME ADULTS 18-65 Cherrytrees Cherrytrees Kitelands Road Biggleswade Bedfordshire SG18 8NX Lead Inspector Rachel Geary Unannounced Inspection 8th June 2006 08:15 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 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.V294801.R01.S.doc Version 5.1 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.V294801.R01.S.doc Version 5.1 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 Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 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 12th December 2005 Date of last inspection Brief Description of the Service: Cherrytrees is a respite care service located on the outskirts of Biggleswade, which shares a site with a domiciliary care service. The accommodation 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 physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. The service has developed some user-friendly information for current and prospective service users, including: a Service User Guide, a Service User Contract and a pictorial shopping list. There was also evidence of pictures being used to aid communication with at least one service user. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 5 Precise information regarding the service’s fees, including any additional charges, was not known at the time of writing. Information provided by the manager set out that there are no fixed fees, and that fees are calculated on the needs and benefit entitlement, of each service user. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 08.15 and 13.30 on 8th June 2006. The inspector spoke to service users, staff, the manager, and the resource manager. The inspector also had a partial tour of the building, and looked at some records. Service users had little verbal communication skills, and could only provide limited information about the support they received. Because of this, the inspector spent a short time observing support. At the time of this inspection, approximately 20 service users were using this respite service, on a regular basis. 2 service users were using the service on the day of this inspection. After the inspection, feedback was provided to the manager and resource manager. Requests were also made for further information to be supplied to the CSCI. By the time of writing, this had been received, and has been included within this report. Also after the inspection, the inspector met with the Responsible Individual for this service, Val Leggatt-Mead. Mrs Leggatt-Mead provided information to show how she intended to address service shortfalls, and demonstrated her commitment to doing so (see inside this report for details). Some of the immediate issues to be addressed included: • • • • • • • staff training plans previous inspection requirements purchasing hairdryers and music systems staffing profiles - including agency staff service user paperwork, including risk assessments a registration application for the manager, and sorting out a specific budget for the service. This report should be read in conjunction with the National Minimum Standards (NMS) for Younger Adults (18-65). What the service does well: Staff treat service users with respect, and there is a relaxed atmosphere within the home. Questionnaires had been sent out by the home to service users and their families. People said different things about the service. Some of the good things were: Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 7 • • • • • • • • (one service user) loves his visits I have found all staff pleasant I have noticed a higher standard of care and staff are more effective there are more organised ‘adventures’ (the flat) is well set out – a home from home setting I like it, I am happy there, but would like to go out more I like going out I like doing house work and being here What has improved since the last inspection? What they could do better: There are still lots of things that could be done to improve the service that is provided. The manager and resource manager acknowledged this during this inspection. To this end, the timescales for a number of the previous inspection requirements have not been met, and have now expired. Revised timescales have not been given within this report. It is paramount that these are addressed as a matter of urgency, or the Commission for Social Care Inspection will be minded to take further action in order to bring about compliance, in accordance with the legal responsibilities of the Registered Provider. Questionnaires had been sent out by the home to service users and their families. People said different things about the service. Some of the things that people thought the service could do better included: • addressing language/communication barriers between service users, their families, and staff DS0000033114.V294801.R01.S.doc Version 5.1 Page 8 Cherrytrees • • • ensuring the respite flat is more homely ensuring there is always food in the fridge freezer, and cupboards, and increasing activities for service users. Some other things that the service could do to make things better are: Ensure that care plans and related paperwork provide sufficient information for staff to meet the holistic needs of service users, and to demonstrate that service users’ assessed needs are being met. In addition, there should be more opportunities for service users to develop their individual skills, and to enjoy experiences associated with every day living. Finally, the service must continue to develop paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for services such as Cherrytrees respite service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 9 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.V294801.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Some useful documentation is available to help prospective service users and their families to be clear about the service being provided at Cherrytrees. A comprehensive assessment process is in place, although this is not always consistently used. EVIDENCE: The manager said that the Statement of Purpose had been updated since the last inspection. A copy was provided afterwards, but as previously reported, some information was still inaccurate, or missing. The Responsible Individual for the home, Val Leggatt-Mead, had also noted this, and had requested that the necessary adjustments be made. As previously reported, the home’s Service User Guide had been illustrated with pictures, to help service users to understand it. Information regarding the home’s assessment procedure was included in the Statement of Purpose. Once again, no assessment information was found on file for one new service user. The manager then produced evidence of the assessment process that was carried out for another new service user, which contained some comprehensive information, including up to date review notes and information from the person’s social worker and previous placement. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 11 Records indicated that a prospective service user had stayed in the unit shortly before their 18th birthday. The resource manager and manager were reminded of the registration categories for this service. A Service User Contract/Terms and Conditions had been developed. Good attempts had been made to ensure this document contained the required information and was user friendly. The contract that was seen on this occasion had been signed by a relative of the service user. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Care plans and risk assessments still do not provide staff with enough information to meet the holistic needs and aspirations of service users. Neither do they adequately promote opportunities for service users to build on their independent living skills. EVIDENCE: As previously reported, a care plan for one new service user contained basic information. The plan included the type written line ‘the care plan agreed to by us is very much to our liking. It is comprehensive and detailed’. There was no evidence that the service user and/or their family/representatives had contributed to the plan. The plan was also not user friendly, and did not include personal goals or make clear links to outcomes from the most recent review. In the case of one service user, no review notes were found. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 13 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. There is still some scope for improving service users’ access to the community, and engaging them in appropriate and meaningful activities during their stay. EVIDENCE: Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 15 Due to the nature of the service, service users’ main educational/occupational needs, are supported by their families/main carers. Both service users left to go to their individual day care services during the inspection. Shortly before they left, one service user was watching TV with headphones (their preference), and the other service user was observed bending over to listen to music from the radio. It was discussed that because of a lack of space in the unit, that service users often watched TV and listened to music in the same room. Each bedroom had a television with a built in DVD player, but there were no music systems to allow service users to listen to music in their bedrooms. A member of staff said that service users sometimes brought their own electrical equipment. It was not clear if these had been PAT (portable appliance testing) however, and it was thought that they had not. It was later said that the service had purchased a ‘digi box’ for the lounge TV, to provide additional channels for the service users to watch. This had not been installed however, because it had not been PAT tested. It was discussed that a hairdryer for the unit would be useful, as service users were not encouraged to bring their own because of the PAT testing rules (see ‘summary’ section of this report). As previously reported, the home had adopted a system called ‘planning your stay with us’. It was intended that a user-friendly chart be completed with each service user on arrival at the unit, covering their preferences with regard to leisure activities and working on independent living skills. In addition, a photo activity chart to record individual’s likes and dislikes had been developed. Once again, there was little evidence of the ‘planning your stay with us’ record being used, on a regular basis. One completed record was seen for one service user, which stated that the person wanted to eat out, watch TV and wash up during their stay. Records indicated that 2 of the 3 activities had been achieved. See ‘conduct and management’ section of this report regarding contact with service user relatives/main carers. The resource manager had previously developed an easy to read draft ‘Personal Relationships’ policy. It was not clear if this had been finalised at the time of this inspection. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 16 The member of staff on duty was observed interacting appropriately with the services users, and providing support at a pace that appeared to reflect the needs of each individual. As previously reported, the home had adopted a pictorial list to aid service users to prepare shopping lists and to carry out the grocery shopping. There were no menus, but service users were able to use this list to help them to choose from some stock items held in the freezer. Service user compatibility was discussed, and it was said that at times, service users were not well matched, when respite stays are planned and booked. It was discussed with the manager that this needed to be a consideration at the point of booking respite visits. It was said that the issue of service user incompatibility, sometimes meant that staff needed to do the food shopping without service users, because there were times when there was only one member of staff on duty, with two services users – one of which would, or could not, go shopping. Service user compatibility had been added to the staff meeting agenda, but there was no known date for the next meeting to take place, and there was evidence that some previously planned meetings had been cancelled. Breakfast on the morning of this inspection consisted of cereal, toast and yoghurt. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Some staff are still not trained to administer medication, which means that the service is dependent on support from the adjacent supported living service. EVIDENCE: The member of staff on duty was observed to be delivering support in an appropriate and respectful manner. Due to the nature of the service, the majority of service users’ health needs are supported by their families/main carers. It was previously reported that staff from the adjacent supported living service, were required to support with the administration of medication within the respite unit. This is because agency staff had not been trained to administer medication, but were still providing a significant amount of support to the unit on a weekly basis. There was evidence that this situation was being addressed, and that regular agency staff would be trained. However, at the time of writing, this remained outstanding. During this inspection, a member of staff came over from the supported living unit to administer medication. When questioned, the staff member was able to explain the purpose of the majority of medication being given out, but not all. In addition, there was limited Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 18 information within one service user’s care plan to explain the purpose and possible side effects of their prescribed medication. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 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 satisfactory systems in place for addressing concerns and complaints, and for protecting service users. EVIDENCE: The home’s Service User Contract/Terms and Conditions document contained information on how to make a complaint. In addition, a user-friendly version had been developed, and was on display in the entrance hall. The manager said that no complaints had been received in respect of this service, since the last inspection. The home was working to the procedures set out in the local multi agency protocol for the Protection of Vulnerable Adults (POVA). No POVA related concerns were noted during this inspection. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment does not fully meet the environmental requirements of the National Minimum Standards (NMS) for Younger Adults (18-65), although good efforts have been made to provide a homely place to stay. EVIDENCE: Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 21 As previously reported, the respite unit is part of the existing Cherrytrees service. The unit operates in conjunction with Aldwyck Housing Association, who are responsible for the maintenance and upkeep of the building, fabrics and furnishings. The accommodation does not adequately meet the NMS environmental requirements, and would also not meet the needs of all individuals with a physical disability. To this end, the home’s long term plan is reprovision. At the time of this inspection, there were still no definite plans for this to take place. In the interim, the CSCI has agreed that the environment must at a minimum, meet the needs of the service users. It was noted that a small area of exposed plasterwork on one of the lounge walls still required attention. In addition, the toilet seat was broken, and had been removed. A member of staff said that it had been reported to the housing association maintenance department, and that it was on a 5-day response job sheet. It was discussed that as this was the only toilet in the unit, that this could cause some difficulties for some service users. A member of staff confirmed that the maintenance issues within the last inspection report had all been addressed with the exception of an uneven paving slab to the front of the building. It was said that this had been looked at, but at the current time was not causing any problems. See also ‘lifestyle’ section of this report. The home was noted to be clean and tidy. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements regarding staff training and supervision, for all staff, are still required. EVIDENCE: As previously reported, the home was using agency staff (‘Tailored Care Services’ following the disbandment of ‘Paveys’), to supplement a small core group of permanent staff. Staff were being recruited according to County Council policies and procedures, and staff vetting documents were being held centrally. By the time of writing, a formal agreement between the CSCI and BCC had been set up about access to, and the inspection of, staff vetting records. A staff proforma for an agency member of staff was seen on this occasion, which indicated that there were systems in place to ensure that staff are recruited in accordance with the Care Home Regulations. Proformas for BCC staff were not yet in place, but there were plans to carry out this work. Original vetting documents were not seen on this occasion. It was discussed that BCC HR planned to verify the validity of checks carried out for agency staff being supplied to the service. Training and development plans for staff had been started. These included some mandatory and specialist training courses, but did not include LDAF (Learning Disability Award Framework) induction training, medication training, Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 23 or NVQs. One agency member of staff confirmed that she had not completed a LDAF induction course, and she did not have an NVQ. There were a number of gaps in training records, and some training was out of date. See also ‘personal and healthcare’ section of this report. As previously reported, there was evidence that supervision for staff, including agency workers, was not taking place on a regular basis. See also ‘lifestyle’ section of this report with regard to staff meetings. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 and 43. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the service. Progress has been slow in a number of important areas. But, there is evidence that the management for this service are committed to making the required improvements. EVIDENCE: A new manager, Moses Daka, had started working at the respite unit on 1st March 2006. Mr Daka’s application to register with the CSCI remained outstanding at the time of writing. The manager provided a copy of an introductory letter that he had sent out to the families of respite service users. The letter stated that he had completed a ‘Care Management Managers Award Level 4’. It was not clear exactly what this was. Mr Daka was working for part of the week, in the adjacent supporting living service, as an assistant manager. It had previously been reported that the inspector had advised, given the numbers of service users (approx 20 – Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 25 although the home’s business plan stated nearly 30), and the amount of work required to address ongoing service deficits, that the part time status of the manager within the respite unit, should be kept under review. Findings from this inspection have not reduced this concern. It was also discussed that to help the manager increase his knowledge of the service users, it would be useful for him to meet with them by working the occasional shift. There was evidence that a manager from a similar service was providing additional support to this service in order to share good practice, and to address service shortfalls. An audit had been carried out which had resulted in a number of health and safety concerns being raised, which included a lack of radiator guards, no emergency lighting in the unit, and no fire extinguisher in the kitchen. Mrs Leggatt-Mead, the Responsible Individual, confirmed after the inspection that the radiator guards and emergency lighting were now in place. In addition, that there were 2 multi purpose Fire Extinguishers in the entrance hall, a short distance from the kitchen. No provider reports, as required by regulation 26 of the Care Homes Regulations 2001, had been received by the Commission in respect of this home, since the last inspection. However, regular communication between the responsible individual and inspector had taken place, including 3 monthly meetings to discuss generic and specific BCC issues. Also, a new system was in the process of being set up, which meant that some of the regulation 26 visits would be delegated to the resource manager for this service. There was evidence that feedback questionnaires were being sent out to service users and their families however, the results of this process had not yet been analysed and used as part of the required quality assurance and monitoring process (see ‘summary’ section of this report for some of the responses). The manager said that he intended to reintroduce relative contact sheets – for recording and maintaining regular contact with service users’ families. There was evidence that a number of local policies and procedures had been developed, but only the manager, and a manager of a similar service, had signed to say that they were aware of these. See also ‘lifestyle’ section of this report regarding PAT (portable appliance testing) tests. No further concerns relating to health and safety were noted during this inspection. An updated copy of the home’s business plan was provided following the inspection. This set out plans to create a specific budget for the home, separate form the adjacent supported living service. Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 26 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 2 2 2 3 X 4 X 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 1 X LIFESTYLES Standard No Score 11 X 12 N/A 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 N/A 2 X 2 X 2 2 X 2 3 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 Requirement Ensure that individual risk assessments are updated and completed in line with the requirements of NMS 9. (Previous timescale of 31/8/05 not met). Ensure that there is a training and development programme for all staff, which incorporates induction, mandatory and specialist training courses and NVQs as required. (Previous timescales of 31/12/03 and 31/8/05 not met). Ensure that an appropriate registration application form for a manager is received by CSCI as agreed. (Previous timescales of 31/5/04 and 31/8/05 not met). All staff must receive training with regard to a basic knowledge of how medicines are used, how to recognise and deal with problems in use, and the principles behind the home’s policy on medicines handling and records. (Previous timescales of 31/8/04 and 31/8/05 not fully met). DS0000033114.V294801.R01.S.doc Timescale for action 08/06/06 2. YA35 18 08/06/06 3. YA37 8 08/06/06 4. YA20 13 and 18 08/06/06 Cherrytrees Version 5.1 Page 28 5. YA39 24 6. YA36 18 7. YA6 15 8. YA13 12 and 16 9. YA39 24 10. YA34 19 11. YA42 23 Ensure that a quality assurance and monitoring system is in place for the home, which fully meets the requirements as set out in standard 39 of the National Minimum Standards for Younger Adults. (Previous timescales of 30/9/04 and 31/8/05 not met). Ensure that staff understand the main aims and values of the home by providing formal supervision to all staff including regular agency members of staff. (Previous timescales of 5/11/04 and 31/8/05 not met). Develop current care plans with the involvement of the service users, to ensure that plans (fully meet the requirements of NMS 6, and) include measurable goals aimed at supporting individuals to maximise their independent living skills. (Previous timescale of 31/8/05 not fully met). All service users must have the opportunity to access the local community, and to engage in appropriate activities both in and out of the home. Visits as specified by Regulation 26 of the Care Homes Regulations 2001, must be carried out on a monthly basis. Copies of the reports must then be forwarded to the CSCI. Completed proformas must be held in the home, for all staff working in the respite unit, as per the CSCI/BCC agreement dated 13.6.06. Ensure the health and safety of service users and staff through the maintenance of all electrical equipment used in the home. 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 08/06/06 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 29 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 YA37 Good Practice Recommendations Consideration should be given to increasing the current allocated hours (specifically dedicated to the respite service), for the manager, to reflect the needs of this diverse and expanding service. (This is a recommendation from the 31/5/05 report). Consideration regarding service user compatibility should be taken into account when booking stays for respite service users. 2. YA3 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Cherrytrees DS0000033114.V294801.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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