Inspection on 26/06/06 for The Cherries

This inspection was carried out on 26th 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Cherries 30/01/09

The Cherries 10/10/07

The Cherries 07/12/05

The Cherries 07/07/05

The Cherries 23/11/04

The Cherries 05/05/04

The Cherries 03/02/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Cherries 30 Julian Road Folkestone Kent CT19 HW Lead Inspector Michele Etherton Unannounced Inspection 26th June 2006 09:45 The Cherries DS0000050913.V297469.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 The Cherries DS0000050913.V297469.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. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cherries Address 30 Julian Road Folkestone Kent CT19 HW 01303 259561 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) Parkcare Homes (No2) Ltd Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: The Cherries is registered to provide care and support for 6 young people with profound learning disabilities and complex needs. It is a large detached home with a spacious driveway in front and garden with patio at the back. All rooms are spacious and airy and all bedrooms are single. There is no lift or access for a person with physical disabilities. There is a high level of staff support to service users living in the Cherries all of the 6 current service users have a contract for one-to-one support. The home is situated close to Radnor Park, the town centre and Folkestone leisure centre. The current fee range for this service is £1158 to £1975 per week. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection starting 9:45 and finishing at 4:40 pm. All six service users were at home at different times during the day and participated as much as they were able to with the inspection. A second brief visit was also made on 29/09/06 to confirm that garden rubble and building materials identified at the visit on the 26th June as posing a health and safety risk to clients, had been appropriately removed and safely re-sited. A manager is in post but there has been a continuous delay in an application for registration being submitted to CSCI, this remains a matter of concern and an outstanding requirement needing to be addressed as a matter of urgency. A programme of recruitment is underway and there have been some improvements to staff shortages and staffing levels, Service users are of a similar age and appear compatible; there has been an improvement in the provision of a more varied range of external activities both during the day and in the evening. Activity programmes are individualised to reflect interests and provide access to new and different experiences. All of the service users are assessed as needing 1-1 to keep well and healthy and to be able to participate in activities within the community safely. This inspection consisted of information gathered before and during the visit to the home, and included observations of staff interactions with service users discussions with staff, feedback was also received from relatives and health and social care professionals through survey information and one face to face interview. Four care staff and the manager were spoken with during the site visit. Other documentation viewed at the site visits included, assessment and care plans, medication records, duty rota, staff employment, induction and training records. What the service does well: What has improved since the last inspection? The service is continuing to add equipment to the sensory activity room to make this a calm and relaxing area for service users. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 6 The laundry area has been upgraded to address the problem of damp. Epipen training has been provided to staff. The commitment of the staff team has seen significant improvements to the health of one service user improving the quality of their life and having a positive outcome in respect of reduced reliance on medication. A learning disability service user forum has been established. A new quality assurance system has been introduced. 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 Cherries DS0000050913.V297469.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 The Cherries DS0000050913.V297469.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. New service users are admitted only following the receipt and review of a professional assessment of their needs and aspirations. EVIDENCE: Discussion with a visiting care manager at the site visit confirmed that full joint assessments had been provided to the home prior to admission of two service users for whom they are responsible. User files viewed evidenced assessment information in place. Staff reported in discussions that they have access to information aout prospective clients prior to their admission to the home. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 9 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): 6,7,9 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Service user plans reflect user needs and aspirations, users are supported and enabled to make decisions and take risks. EVIDENCE: Three Service user plans were viewed at this visit , improvements have been made to the level of detail within plans in addition to the development of supporting information around daily routines. The home has also developed a summary version of individual users needs, likes,dislkes, medicastion etc., for use in emergencies. The home is in the process of introducing person centred user plans to enable users greater involvement, One service user confirmed they had been actively involved in the development of their user plan. A visiting care manager reported that they were very happy with the home, and could not fault it, they found the home maintained good communication with them in respect of their service users, and had dealt appropriately with situations that had arisen. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 10 Two service users with good communication skills are more actively involved in making personal decisions and choices, staff reported that they facilitate decision making for those users without more developed communication skills, by an awareness of individual users’ body language and mannerisms to reflect their moods etc, this aids staff in determining the wishes and preferences of service users. In discussion, staff’ indicated that they undertake informal risk assessment of individual users’ mood and behaviour, and the risks within the planned activity prior to going out, this is not recorded and the home may wish to strengthen the risk assessment framework by more clearly evidencing this. Staff feedback indicated a proactive approach to risk taking and stated no activity would be ruled out without due consideration of risks first. A varied range of formal written risk’ assessments’ that promote opportunities for greater individual independence were also viewed on service user files. Good interaction was observed between service users and staff throughout the visit. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15,16,17 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Service users are supported and enabled to develop an active programme of activities retain a community presence and make use of local facilities. Service users are supported and facilitated to maintain links with their families. The home should consider ways in which it can facilitate all service users actively participating in development of menus. EVIDENCE: Feedback from staff and review of user files and staff communication records indicated there has been improvement to the range and variety of external activities provided to service users. As all of the service users are assessed as needing 1-1 support, the ability of the home to meet the needs of users in these areas can be affected by reduced staffing levels (see standard 33) . The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 12 A visiting care manager at the time of the visit reported that their service users “ have very busy activity programmes”, users were observed during the visit attending external activities e.g swimming, shopping, and in one case planning a cooking session later that day. One service user reported that they attended regular horseriding sessions and gave information as to what this entailed. Staff confirmed service users already attend a number of evening activities within the local community, but the manager and home staff are considering how this can be extended. Discussion with staff and users provided evidence that regular contacts are maintained with families, and for some service users these contacts are sufficiently regular to form part of their weekly activity programme. Staff have an awareness of dietary issues concerning the service users and develop the menus accordingly. Users eat in the dining area together and are involved in some food preparation and shopping activities. There was evidence that as a result of staff input in respect of one users diet there had been improvements to their general health and quality of life. Two clients with good communication have been actively involved in development of the menus and this was discussed with the manager who is aware of the need to find strategies for involving all the service users. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 13 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): 18,19,20 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. Personal support routines are developed with reference to users personal preferences where known. Service users where able to are involved in the development of personal routine information. Service users have access to routine healthcare; there is a need for improved recording by staff to more clearly evidence frequency in this area etc. Service users are protected by a staff team who are appropriately trained in the administration, recording and storage of medication. EVIDENCE: Staff’ were observed interacting appropriately with service users and using diversions to minimise behaviours that may precipitate less sociable behaviour. A review of three case files provided evidence of detailed information around personal routines, staff feedback indicated these are flexible. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 14 The home were able to evidence that they have sought appropriate healthcare interventions for service users, but need to ensure improved recording and frequency of routine healthcare appointments for some service with more comoplex needs. Staff confirmed service users are weighed monthly, gains or losses are noted and actions taken in respect of this An outstanding recommendation to review some PRN medication procedures has been addressed. A review of medication storage and security was satisfactory, the manager advised that routine temperature recording of storage areas is being undertaken, records of this were not viewed on this occasion. All current staff administering have received medication and epipen training, a list of staff signatures is in place this needs updating with additional detail for those staff from transferred in from other homes on a temporary basis. MAR sheets were viewed and were completed appropriately, including recording receipt of medications. One service user is receiving eye drops and the home will need to ensure that staff have been appropriately trained to administer these correctly, a recommendation has been issued in respect of this. The manager advised that a monthly medication audit is being implemented as part of the new quality assurance process it was suggested that the home incorporate liquid medications into this and that they ensure all liquid medications are routinely dated upon opening to support the audit process, and a recommendation has been made. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 15 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): 22,23 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place, complaints are actively responded to, service users and interested parties would benefit from being reminded of the procedure. Service users are protected from abuse, neglect and self harm, strategies for managing user behaviours would benefit from improved clarity around levels of interventions to be used. EVIDENCE: The home have advised in pre-inspection information that one complaint has been received, the manager advised this is being dealt with by the area manager. The manager does not have a complaints file at present and was urged to develop one, the home retains a complaints book in the downstairs area, and any complaints made directly to the home are recorded in. One survey returned from a relative indicated that they did not know about the complaints procedure, but expressed confidence in being able to make a complaint if needed. Feedback from a health professional indicated that they had made a past complaint on behalf of a service user and this had been satisfactorily resolved. The manager was reminded that expressions of concern should also be recorded, whilst this is not an issue for most relatives, the home was able to evidence that it is recording concerns from some relatives. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 16 A number of staff have undertaken adult protection training, the manager is aware this needs to be extended to all staff and a training programme is in place. The Home staff have an awareness of adult protection issues and are responding appropriately as issues arise. One service user is currently the subject of an Adult Protection resulting from issues external to the home. The care manager for this individual has expressed satisfaction in the way the home has managed this situation. Behaviour management strategies are in place on user files and staff are being trained in CPI, the home will need to ensure that any training involving techniques for physical restraint or control should be accredited through BILD, consideration should be given to clarifying within behaviour management strategies, the level of CPI interventions approved for the service user concerned, these strategies should be developed in conjunction with the CM, relatives and user where possible and reviewed on a regular basis and this is a recommendation. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 17 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): 24,30 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. The home provides a clean comfortable environment for service users, is maintained to a good standard but would benefit from upgrading in the near future of areas experiencing heavier use. EVIDENCE: An outstanding requirement in respect of the laundry has been addressed, the area affected has been replastered, the room has natural ventilation but this is inadequate, the manager is seeking quotes currently for the installation of an external extractor vent for managing the condensation within the laundry area The kitchen area is showing signs of wear with several missing doors on cupboards and is in need of upgrade, the manager advised this is planned and is awaiting the appointment of a new maintenance person. The external rear garden area is well laid out for service users providing a pleasant level space for them to relax. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 18 A ladder had been left propped up against the wall, this was unsecured and posed a security risk, the manager had this moved and secured during the course of the visit, A side garden wall has partially crumbled and debris and rubble, had been left with patio building materials on a patio near to the house, a discussion with the manager as to how this might impact on the health and safety of service users resulted in an agreement that the rubble would be removed and the building materials moved and made safe, a second site visit on 29/6/06 confirmed these issues had been addressed. The manager agreed to cover over building materials located to the rear of the garden to further protect service users. The existing patio area to the rear is uneven and sunken in some places, the home will need to consider whether a risk assessment needs to be developed for this area and whether remedial action needs to be taken in the event of further deterioration. The home was clean and tidy there were no residual smells, bedrooms were individually personalised, although the whole home has some signs of wear and tear, one bedroom had a broken bed and the manager advised that this has occurred as a result of the users behaviour, a special bed is being made to try and resolve the issue of repeat breakages. Staff spoken with had an awareness of universal precautions, and appropriate separation of foul and normal laundry, not all staff have received infection control training (see standard 35) although in house training is to be arranged. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 19 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): 32,33,34,35,36 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to this service. More than 50 of the staff team have achieved NVQ2 . Further improvements are needed to staffing levels to ensure there is the correct level of 1-1 support for service users at all. Improvements are needed to the recruitment procedure to ensure that all appropriate checks are in place and service users are protected. The home has a good programme of qualification and specialist training and development in place for staff but must ensure that all basic mandatory training has also been achieved or maintained. Staff are provided with regular supervision and their development, training and practice reviewed. EVIDENCE: A training matrix was viewed at this visit; the home have worked very hard to achieve more than 50 NVQ2 qualified staff. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 20 Consultation with staff in respect of a previous recommendation regarding length of shifts has been undertaken, staff spoken with are satisfied with the length of shifts now that rotation of work with service users has been implemented, this stimulates interests and and enables more effective support to be offered to users. The duty rota was reviewed and discussed, there has been an active programme of recruitment and this has made some improvement to staffing levels, however, there continue to be difficulties in making sure there are sufficient staff on duty in addition to the manager to fulfil the one-to-one contracts agreed at all times, and this remains an outstanding requirement. Four staff files were viewed at this visit, of these, 1 was without evidence of CRB or equivalent, two had no evidence of references, all had items of ID, one had current photos in place, application forms were not evident for two, terms and conditions information was also not present on all four files. The home must ensure that they can demonstrate that the recruitment of staff has been robust and all required checks and references have been taken up, staff file content should be compliant with schedule 2 of the Care Homes Regulations 2001. It was suggested that in those instances where the home has received an unclear CRB for a prospective staff member, they must record clearly on what evidence they have made a decision to employ, they should also provide evidence within this of risk assessment, a requirement has been issued in respect of these shortfalls. The home are currently considering ways to actively involve service users in staff selection, and are considering offering relevant training and guidance to a service user representative. Staff spoken with confirmed they had access to the company induction programme the manager was aware of the new sector skills induction standards and a new induction pack is to be used with new staff, the home must ensure this incorporates LDAF for those new to learning disability services. Some staff are still to achieve all core mandatory training, a training programme is in place for this and there was evidence of planned training in the near future, it is recommended that all staff are updated with mandatory core skills. Staff files viewed provided evidence of individual training profiles, and supervision and appraisal systems routinely incorporate training and development of staff. Staff supervision records were noted and staff confirmed access to regular supervisions with the manager. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to this service. The manager needs to be registered, this remains a matter for concern. The manager has a good understanding of the needs of users and a clear vision of how she wants the service to develop to support them. A nationally agreed quality assurance process is being implemented and the company are actively seeking ways to involve users in service development and improvements, The home is generally well maintained, with a range of environmental and individual user risk assessments in place EVIDENCE: The manager has been in post since february 2005, previous applications for registration appear to have become lost at the company head office and have failed to reach the CSCI office at Ashford, whilst the manager demonstrates The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 22 commitment and a clear vision for the development of the service, and has already implemented some positive changes, it has not been possible todate to confirm her fitness as a manager through the application for Registration process; this remains a matter for concern and an outstanding requirement. A further application form will be sent to the manager for completion. The company has introduced a new quality assurance programme but this is yet to be fully implemented within the home. An outstanding requirement to develop systems for user participation has been addressed with the company initiating a service users forum, minutes of the first meeting were provided at this visit. Service user working parties are also being established to look at issues coming up from house meetings, owing to difficulties of communication for the majority of service users in the house, house meetings have not been held routinely, this was discussed with the manager, the home will need to consider innovative ways of engaging with all the service users to try and guage their views. The manager is also considering ways in which service users can more actively be involved in the running of the household including undertaking health and safety checks alongside staff. It is a recommendation that the house can evidence how greater service user involvement and input is influencing service development, and can provide annual analysis through development of an annual quality assurance report The home is generally well maintained, the recruitment of a home specific maintenance person will help with implementing a programme of minor upgrading around the home e.g. Kitchen, upstairs bathroom. Environmental risk assessments are in place and consideration will need to be given as to whether the patio area should be further risk assessed in view of the deterioration in the paving, any building or upgrade works taking place whilst residents are still in the building will also need risk assessing. All servicing and checks including Gas, electricity, and PAT testing have been undertaken, fire extinguishers have been serviced. Accident records viewed indicated a low level of service user accidents and these are recorded appropriately. Incident recording is being undertaken, however, discussion with the manager revealed there is no formal procedure for the analysis of incidents and how this may impact on behaviour management strategies, consideration should be given to introducing this. There are continuing problems with the homes heating system a replacement system is to be installed whilst service users are away; a date for this is still to be set. A recommendation regarding the use of portable heaters and appropriate risk assessment of these remains outstanding. The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 24 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 YA33 Regulation 18 (1) (a) Requirement Make sure that there are sufficient staff recruited in the team to carry out planned activities fully and fulfil one-toone contracts and meet assessed needs at all times (previous timescale partially met 10/02/06) The home must ensure that they can demonstrate that the recruitment of staff has been robust and all required checks and references have been taken up, staff file content should be compliant with schedule 2 of the Care Homes Regulations 2001. Where unclear CRB’s are received the home must record clearly on what evidence they have made a decision to employ, they should also provide evidence within this of risk assessment. An application to be registered manager needs to be submitted to CSCI. (Previous timescale of 27/01/06 not met) Timescale for action 31/07/06 2 YA34 19 31/07/06 3. YA37 9 (1) 31/07/06 The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA17 YA20 Good Practice Recommendations Home to consider ways to improve involvement of service users with reduced communication skills in the development of menus Home to ensure that administering staff have been appropriately trained to administer eye drops correctly The Home to incorporate liquid medications into medication audits, liquid medications to be routinely dated upon opening to support the audit process. The home will need to ensure that any training involving techniques for physical restraint or control should be accredited through BILD, Behaviour guidelines to indicate the level of CPI interventions approved for the service user concerned, these strategies should be developed in conjunction with the CM, relatives and user where possible and reviewed on a regular basis. All staff are to be updated with mandatory core skills. Home to evidence how user views are influencing service development through house meetings, working parties and the user forum, an annual quality assurance report to be developed 3 YA23 4 5 YA35 YA39 The Cherries DS0000050913.V297469.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 The Cherries DS0000050913.V297469.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. 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!