Care Home: Cherry Leas Residential Home

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What has improved since the last inspection? There have been improvements overall in record keeping, including documents related to care planning and risk assessments. People living in Cherry LeasCherry Leas Residential HomeDS0000072864.V374998.R01.S.doc Version 5.2 Page 6may be confident that their needs are recorded and staff have the plans in place to understand how to meet these needs. Some improvements to the environment have been noted since the last inspection. These include new carpets in some individual bedrooms and new automatic door closers on bedroom doors. Visitors spoken with said they felt the standard of cleanliness throughout the home had improved recently. What the care home could do better: The home should continue with ongoing improvements to the maintenance of the premises. In particular areas of damage that may have an impact on health and safety or infection control such as the laundry floor should be improved. The management team should continue to develop the home`s quality assurance system to include a development plan for the home that demonstrates that the service is being run in the interests of people who live there and their wishes are being taken into account. The management team should consider what improvements may be necessary to the storage of medication, to include an appropriate facility for the storage of controlled drugs. Key inspection report CARE HOMES FOR OLDER PEOPLE Cherry Leas Residential Home 7 Third Avenue Clacton-on-sea Essex CO15 5AP Lead Inspector Ray Finney Unannounced Inspection 5th May 2009 10:00 DS0000072864.V374998.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Leas Residential Home Address 7 Third Avenue Clacton-on-sea Essex CO15 5AP 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) 01255 221 726 01255 221 726 Mohammad Joomun Bibi Joonum Post vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 16 23rd January 2008 2. Date of last inspection Brief Description of the Service: Cherry Leas is an established care home that provides residential care for older people. It is a detached house situated in a quiet residential are of Holland-onSea. The home offers single room accommodation on the ground and first floor for up to sixteen service users. Eight of these rooms have en-suite facilities of a toilet and wash hand basin; the remainder have a wash hand basin. There is a bathroom on the ground floor and a bathroom and shower room on the first floor. Access to the first floor is by means of a passenger lift or stairs. There are flowerbeds to the front of the property and some off road parking. Access to the rear garden is through the sun lounge. The rear garden is mostly laid to lawn with fruit trees, rockery and flowerbeds. Other communal areas comprise of a pleasant dining room and lounge. The home is situated close to the sea front with local shops, doctor’s surgeries and churches close by. The home charges between £390.00 and £450.00 a week for the service they provide. Other services such as hairdressing and chiropody are available at an additional charge. This information was given to us in May 2009. Information about the home can be obtained by contacting the home’s manager. Inspection reports are available from the home and from the CQC website www.cqc.org.uk Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key inspection for the home since it was registered under the new provider. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Completed surveys were received from members of staff and the relatives of people living in the home. An unannounced visit to the home took place on 5th May 2009. On the day of the visit the atmosphere in the home was relaxed and welcoming and we were given every assistance from the manager and the staff team. The visit included a tour of the premises, discussions with people living in the home, visitors, the manager and members of staff. Observations of how members of staff interact and communicate with people living there have also been taken into account. What the service does well: Staff know people well and understand how to meet their needs. A member of staff who completed a survey told us that what the home does well is, “treats residents well, makes them happy and comfortable”. Relatives are made welcome and are complimentary about the service provided. One relative who completed a survey stated, “Cherry Leas is the best home in Clacton” and when asked what they could do better they responded, “Nothing. They are the best in my view”. Staffing levels are good and people’s needs are seen to promptly. People spoken with said they enjoy the food provided by the home. Mealtimes are relaxed and sociable occasions. What has improved since the last inspection? There have been improvements overall in record keeping, including documents related to care planning and risk assessments. People living in Cherry Leas Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 6 may be confident that their needs are recorded and staff have the plans in place to understand how to meet these needs. Some improvements to the environment have been noted since the last inspection. These include new carpets in some individual bedrooms and new automatic door closers on bedroom doors. Visitors spoken with said they felt the standard of cleanliness throughout the home had improved recently. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable as the home does not offer intermediate care. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Through the comprehensive admission process people choosing to live at Cherry Leas can be confident their needs will be met. EVIDENCE: On the day of the inspection the manager explained that the provider is in the process of updating the home’s Statement of Purpose and Service User Guide. This is to update the information relating to the management of the home as a result of the recent change of manager. The home does not currently have any vacancies but the manager is confident that the minor changes to the Statement of Purpose and Service User Guide will be in place before the information is required for any prospective service user. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 9 A sample of three service users’ records was examined and all contained appropriate pre-admission assessment documentation. Areas covered in the assessments include physical health, mental health, social needs and current medication. In addition, where individuals are admitted through local authority processes, there is also a social services assessment in place. Records examined confirm that the assessments have been reviewed recently and care plans developed from the person’s assessed needs. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can expect their personal and healthcare needs to be identified and to be provided with the support to ensure these needs are met as they would wish. EVIDENCE: On the day of the inspection a sample of three care plans was examined. It is evident that the care plans are developed from the information gathered in the assessment process. There have been improvements since the last inspection in the information contained in the care plans. The manager explained that, together with the new provider, they are updating all the care plans using a new format. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 11 The new care plans identify the area of need, state what the care objective or outcome is for the individual and give a detailed action plan to guide staff in providing appropriate support around the assessed need. Care plans examined covered a variety of needs including Personal Care and Physical Wellbeing, Diet and Weight, Sight, Hearing and Communication, Oral Health, Foot and Hand Care, mobility and Dexterity, History of Falls, Continence, Medication, Mental State and Cognition, Personal Safety and Risk, Family Contact and Relationships and Sleep Pattern. There were also a range of risk assessments in place including Falls, Moving and Handling and a Nutritional Risk Assessment. Through discussions the manager demonstrated a commitment to updating all the residents’ care plans to a similar standard, but acknowledged that this is taking time to complete. As reported at the last inspection, staff spoken with, including the manager, were able to demonstrate a good knowledge of the individual needs of people living in Cherry Leas and this continues under the new manager. People spoken with were happy with the care they receive and visiting relatives also made positive comments about the care provided in the home. They told us they, “couldn’t fault the home”. Records examined contained evidence of input from healthcare professionals including District Nursing services. During the course of the inspection a doctor visited one of the people living in the home. The manger was able to demonstrate a good awareness of people’s healthcare needs and senior staff were observed discussing individual’s needs around healthcare appointments with the manager. As at the previous inspection, Cherry Leas operates a Monitored Dose System for administering prescribed medicines. A tour of the premises confirmed that medication is stored securely in two locked cupboards. The cupboards were clean and tidy. Medicines Administration Record (MAR) sheets were examined and found to be completed appropriately with clear recording of what was given signed by the member of staff. At the time of the last inspection we reported that controlled drugs are stored in a locked metal safe inside a locked cupboard. Amendments to the Misuse of Drugs (Safe Custody) Regulations now state that care homes must store controlled drugs in a controlled drugs cupboard, including care homes registered for personal care and not just in nursing homes. The requirements are that controlled drugs should be stored in a metal cupboard of specified gauge with a specified double locking mechanism and should be fixed to a solid wall. This was discussed with the manager who agreed that he would discuss Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 12 it with the proprietor and with the pharmacy that supply the home’s medication. Throughout the inspection we observed that staff followed good practices and spoke respectfully to people living in the home. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are being offered the opportunity to engage in meaningful and enjoyable activities, which meet their preferences and interests. EVIDENCE: Cherry Leas continues to offer people living there a range of activities to meet their needs and wishes. Records examined documented some of the activities that take place and the manager was able to explain the kinds of activities that go down well with people in the home. These include bingo, ‘singalongs’, war songs, quizzes in the morning and carpet bowls. The manager said people like it when staff do activities around reminiscence. There is a volunteer who comes in once a fortnight to play the piano and a singer comes in about every six weeks to entertain people. Every Thursday a volunteer comes in to run an armchair exercise and movement session. We also discussed less formal activities with the manager. He explained that they Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 14 try to look at what the individual likes to do and support them to do it where possible. He said one person had a background in catering and likes to help lay tables and clear away dishes so they support the person to help with this activity. Visitors spoken with said they have seen people taking part in bingo sessions and musical entertainment. They said they popped in regularly and were made welcome. People’s religious needs are catered for, in particular a representative from a local church comes in weekly and offers Holy Communion for those who want to take part. As at the last inspection, people were observed to make choices about things they want. The manager explained that they have meetings with residents to empower them to make decisions. The cook now regularly asks people about their choice of food and an alternative is offered if they do not want to have the main meal. Lunch on the day of the inspection was roast turkey with roast and mashed potatoes, Yorkshire pudding, roast parsnips, carrots and swede. Some people had apple pie and custard and some had ice cream for dessert. Earlier in the day the cook had made a Victoria sponge cake for tea. The meal was observed to be relaxed and sociable. The food looked appetising and people spoken with they, “enjoyed the dinner”. Visitors also said, “the food is good”. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their concerns about how they are treated are listened to and acted upon as stated in the complaints and safeguarding procedures. EVIDENCE: Cherry Leas has an appropriate complaints procedure in place. Since the last inspection there have not been any formal complaints received by us and there were none recorded by the home. Through discussions the manager was able to demonstrate how they deal with minor concerns as and when they arise. Recording how minor concerns are dealt with would provide evidence of good practice and the manager was keen to make any improvement that would develop and enhance their record keeping. Visitors spoken with on the day of the inspection said they had not felt the need to make a complaint but were confident they could bring up any concerns they may have with staff or the manager. A sample of personnel records examined contained appropriate Criminal Record Bureau (CRB) checks. The manager explained that the new provider has updated safeguarding training (previously referred to as Protection of Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 16 Vulnerable Adults or POVA). Staff spoken with were aware of their responsibilities around recognising and reporting abuse or poor practice. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can enjoy living in an environment that suits their lifestyle and which is homely, well maintained and clean. EVIDENCE: As part of this inspection we carried out a tour of the premises and noted a general improvement since our last visit. As previously reported people’s individual rooms were personalised with ample evidence of their own possessions such as ornaments and family photographs. Some rooms have had new carpets and the manager explained that there are plans for renewal of all carpets throughout the home. Since the last inspection all individual bedroom doors have been fitted with automatic door closers which are linked Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 18 to the fire alarm system. New commodes have been provided for those people who need one. It was noted that many of the people living in the home are becoming more forgetful as a result of the aging process. We discussed with the manager how signage around the home could be improved to assist people who are becoming forgetful. This includes appropriate pictures or signs on individual bedrooms as well as bathrooms and toilets. We observed that the home was clean throughout and there were no unpleasant odours. Maintenance has improved but there are some minor issues that could be improved. One of these is minor damage to the laundry floor near the door that was identified at the last inspection. This needs to be addressed to ensure people are protected by good infection control. Bathrooms and toilets contain liquid soap and paper towels to enable staff to follow good practices around infection control. On the day of the inspection staff were observed washing hands appropriately. Visitors spoken with said they felt “the standard of cleaning has improved”. Overall Cherry Leas is comfortable and has a homely atmosphere. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be confident they are cared for by a competent staff team who can meet their needs. EVIDENCE: On the day of the inspection we observed that staffing levels were good and people’s needs were being attended to promptly. It was noted that staff interacted well with people in the home. Through discussions the manager was able to demonstrate that they are continuing to support people to achieve a National Vocational Qualification (NVQ). The home has 18 care staff, two cooks and one domestic; out of the total of 21 staff, 15 have either completed or are in the process of doing NVQ. This is an ongoing improvement since the last inspection. A sample of three personnel records was examined and showed some improvements in how the records are organised. The manager explained that quite a few of the staff team were recruited many years ago when the process was not formalised, consequently some documents that are now required by regulation are not available. However, the new provider and manager are Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 20 taking steps to ensure, where possible, these are obtained. They now have in place documents such as relevant proofs of identity and up to date photographs. However, some documents such as two written references are not available for staff who have been in post for a number of years. The process is now more robust and relevant documentation, including two written references, is now sought for all prospective employees. Criminal Record Bureau (CRB) checks have recently been re-done for all staff. The new provider has put in place a training planner and although all training for all staff is not yet complete, they have identified what training is needed and they have started to roll out planned training across the staff team. Records examined contained evidence that there is a range of training either completed or ongoing for a few more staff. All staff have received manual handling training; other training includes infection control, fire training, dementia care and training around respect and dignity. Some of the training is provided ‘in-house’ and some is provided in conjunction with the local Primary Care Trust. There was also evidence of training around blood glucose monitoring to support people with diabetes. On the day following the inspection the pharmacy supplying Cherry Leas with their medication were coming to the home to provide staff with training around the Monitored Dose medication system. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Cherry Leas is appropriately managed in the best interests of people living there. EVIDENCE: Since the last inspection the manger has left and the deputy manager has taken over the role. The new manager has many years experience in the field of care, including some years in a supervisory capacity. He has almost completed a National Vocational Qualification in care and then plans to achieve the Registered Manager’s Award (RMA). The manager was able to demonstrate a good awareness of his management responsibilities and was Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 22 keen to develop his skills around management and provide evidence that Cherry Leas is a well managed home. Visitors spoken with told us that they found staff and management, “very accessible”. We discussed at length the home’s processes around quality assurance with the manager. Although there has not been progress in formalising the process, it is evident that people’s opinions are sought. The new provider has already made a number of environmental improvements in response to the views of residents and their families. At the time of the last inspection a recommendation was made that the manager should continue to develop the Quality Assurance system so that when they seek the views of people living in the home and other interested parties, the information is used to form a development plan, which demonstrates that people’s views are being acted upon. This is an area for improvement that the new provider and manager should develop. As previously reported the home only manages small amounts of spending money for items such as chiropody and newspapers. All spending is recorded and receipts are kept so that there is an audit trail. All individual monies are stored securely in a locked safe. A sample of Health and Safety documentation was examined and all found to be in order. This included certificates relating to the maintenance of the lift, fire alarms, emergency lighting and gas appliances. The manager explained that they now have taken out a new contract for clinical waste disposal. There is a comprehensive fire risk assessment in place. Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Cherry Leas Residential Home DS0000072864.V374998.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP9 Good Practice Recommendations The manager should continue to update care plans until they are all up to the improved standard noted in the new care plan format. The provider should consider how they will ensure there is an appropriate storage facility for controlled drugs should anyone living in the home be prescribed medication that requires this level of secure storage. Better signage around the home would assist people who are becoming forgetful, including clear pictorial signs on bathrooms and toilets and relevant personal pictures on people’s bedroom doors. The provider should ensure that repairs are carried out to the laundry floor so that it is more easily cleanable , which would reduce the risks of cross infection. The manager should continue to develop the Quality Assurance system so that when they seek the views of people living in the home and other interested parties, the information is used to form a development plan, which demonstrates that people’s views are being acted upon. DS0000072864.V374998.R01.S.doc Version 5.2 Page 25 3. OP19 4. 5. OP26 OP33 Cherry Leas Residential Home Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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