Inspection on 17/08/09 for Cherry Holt Care Home

This is the latest available inspection report for this service, carried out on 17th August 2009.

CQC found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cherry Holt Care Home 13/02/06

Cherry Holt Care Home 16/08/05

Cherry Holt Care Home 30/03/05

Cherry Holt Care Home 06/07/04

Cherry Holt Care Home 18/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Cherry Holt Care Home Welham Road Retford Nottinghamshire DN22 6TN Lead Inspector Stephen Benson Key Unannounced Inspection 17th August 2009 09:00 DS0000024634.V377210.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 Holt Care Home DS0000024634.V377210.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 Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherry Holt Care Home Address Welham Road Retford Nottinghamshire DN22 6TN 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) 01777 710347 01777 710499 rak@fbccarehomes.com Mr K Sooriah Mrs L M Sooriah Mr Soopramanien Chendrayah Sooriah Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (3) of places Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th September 2007 Brief Description of the Service: Cherry Holt is a care home providing personal care including nursing care and accommodation for 52 older people or up to 3 beds can be used for people with a physical disability. The home provides short and long term care. The home is owned by FBC care homes which is run as a family business. The home is located on the outskirts of Retford where there are shops, pubs, post office and other amenities. The home was opened in 1996 and consists of a purpose built building. All of the homes bedrooms are single with en suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. The home has a garden to the rear that is well maintained and easily accessible. There is car parking available for 16 cars and have their own mini bus. The home has achieved Investors in People status. The manager said on 17/08/09 that the fees for the service range from £407 £581 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. A copy of the latest inspection report was available in the entrance hall. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people accommodated and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This was our first visit to the home since 1st April 2009. This inspection involved one inspector; it was unannounced and took place in the daytime, including lunchtime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. We sent survey forms entitled ‘Have your say about…’ to a sample of people and 13 of these were returned. The main method of inspection used is called ‘case tracking’ which involves looking at the quality of the care received by a number of people living at the home. We also use evidence from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the people’s needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Anyone new moving into the home is provided with up to date information about the home and they are assessed to establish that their needs can be met. One person commented how ‘blown away’ she was at the genuine warmth and friendliness she was shown. People are involved in preparing and reviewing their care plans and said they receive a very good standard of care. One person told us “I have had two new care plans since I have been here, they give me them to read, I can take as long as I want. People receive the healthcare they need and one person sent a thank you card saying, ‘Thank you for nursing me back to health so I could go home’ Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 6 There are suitable arrangements for the safe storage, handling and administration of medicines and people are assessed to see if they are able to self medicate. Staff and residents are involved in the Dignity in Care challenge which has been made into a training programme for staff to achieve the status of being a Dignity Champion. One person commented, ‘I love the way that all the staff know my name’ There are frequent opportunities for people to take part in group and individual activities both in and out of the home. Some residents join in with the planning and running some of the activities. Residents enjoy the musical entertainers that come to the home and people commented, ‘I especially like the musical concerts that we have and I’d like to say how good the hairdresser is’ and ‘I like the fact we have musical concerts and that my granddaughter is allowed and invited into the home to play her keyboard, this is very important to me’. People are able to make choices and a record is made of any changes. One person commented, ‘Staff listen and act on suggestions’ and another person said, “We just have to say what we want and they do it, they are wonderful”. A new menu has been prepared through discussion in residents’ meetings which provides choices at each meal, and people can always request an alternative. Comments made about the food included, “There is a choice every day about what we eat”, “We just have to say if we want something different like soup or a sandwich” and “The food is good and I get plenty of it”. . People are provided with information about how to make a formal complaint and are encouraged to raise any smaller matters on a daily basis. One person told us, “Just tell whoever and it gets to Rak (The manager) who comes to sort it out”. There have not been any allegations of abuse, but staff were aware of what they should do in the event of one being made. The building was nice and clean and repairs are carried when needed making it a pleasant place for people to live. Staff know what they need to do to stop any infection spreading around the home, including wearing protective clothing, so that people are not put at risk of being made ill. One person commented, ‘Most important for me is cleanliness and this home is spotless. The bedding is always lovely which I really like’. New staff only come to work in the home once they have been through the checks they need to show they are of good character and suitable to work with vulnerable people. Staff are provided with training, including an induction for new staff, to make sure they know how to meet the needs of people living in the home. One person told us, “The staff are so flexible, they will do anything for you”. Other people commented, ‘I am not lonely because staff are always Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 7 calling in to talk and ask if I need anything’ and ‘I really love the night staff and all the carers are so kind’. The home is well managed and people are encouraged to put forward ideas and suggestions about the running of the home. Regular checks and tests are carried out on the building and equipment, including the fire alarm and water storage system to protect the health and safety of residents. What has improved since the last inspection? 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 Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 8 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 Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 9 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 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with the information they need to decide if they want to come to the home, and will know that every effort is made to ensure their needs will be met. EVIDENCE: The home’s Statement of Purpose and Service User Guide have been updated and include information about the Mental Capacity Act, Deprivation of Liberty and how the home is responding to the dignity challenge. They also show the registering authority as the Care Quality Commission who took over from the previous regulator on 01/04/09. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 10 The updated Statement of Purpose has been distributed to residents and is available in the entrance foyer. The home’s admission policy has been reviewed and updated to include that care plans will be written within 48 hours in the event of an emergency admission. In our survey forms eight people said they received enough information before moved in and one person said they did not. Two of the people case tracked were admitted to the home since the last inspection. Both had pre admission assessments completed prior to moving to the home, as well as other background information. One of the assessments had highlighted the need for some changes to be made to the living accommodation, which was carried out before the person moved into the home. A relative told us, ‘Our relative chose this placement and Rak (The registered manager) organised for the washbasin to be moved to a better position, new doors were fitted too. He moved the furniture around to make the best possible space.’ The manager and clinical manager said they organise carrying out assessments between themselves and the provider. The manager said either the provider or clinical manager, both of whom are registered nurses, always go on assessments for people needing nursing care. In addition the manager said an assessment completed by the Local Authority is obtained if they are funding the placement. Staff said they know about any new admissions to the home and that assessment information is made available prior to the person coming to live at the home. One recently admitted person commented in a residents’ meeting that on the day she came into Cherry Holt to live how ‘blown away’ she was at the genuine warmth and friendliness she was shown. Another person said, “I was told all about the home when they came to see me”. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 11 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in the planning of their care and can contribute to the delivery of this where possible, including involvement in promoting dignity in care. EVIDENCE: We were told in the assessment they completed that, ‘All service users continue to have detailed and individualised care plan with input obtained from both the service user and or their representatives. Our care plans reflect the individual needs and wants of our service users, enabling us to deliver care suited to service user needs. Care plans are now more detailed and include preferences and choices for each service user and the addtion of a Mental Capacity Assessment to implement the Mental Capacity Act 2005.’ Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 12 A sample of four care files were seen. The care sections had all been reviewed and updated monthly by one of the nurses, and the social sections had been reviewed by the activities coordinator. There were appropriate references seen to equality and diversity. The care files included various risk assessments including those to promote tissue viability and nutrition. Where a need was identified through the risk assessment there was a care plan in place as to how that need should be met. One person with restricted mobility had a care plan describing what pressure relieving equipment should be used. Where people required assistance with mobility there was a moving and handling plan, and each file included a Mental Capacity Act and Deprivation of Liberty assessment. Staff said they found the care plans useful, they say what the person can and cannot do for themselves as well as their likes and dislikes. Staff said they liked the social history as it helped them to know how to relate to people. In our survey forms twelve people said they receive the care and support they need and one person said they sometimes do. One person commented, ‘Very good standard of individual care’. One person told us “I have had two new care plans since I have been here, they give me them to read, I can take as long as I want. There was information of healthcare provided and any ongoing treatments. One file included details of physiotherapy exercises one person has to do and a chart showing these were taking place as required. We were told in the assessment they completed that, ‘.Within the care plan separate entries are entered for any visits from other health care professionals as well as entries for investigations and there outcomes’. Staff said they do everything they can to promote people’s well being, including promoting their hygiene, asking them how they are and monitoring any concerns. Anyone at risk of developing a pressure sore is identified and closely monitored. In our survey forms twelve people said they receive the medical support they need and one person said they sometimes do. One person told us, “My health is very well looked after” and a thank you card was seen which said, ‘Thank you for nursing me back to health so I could go home’. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 13 The medication records seen were fully completed as was the controlled drugs register. At the last pharmacy inspection in September 2008 there were no issues arising and no recommendations were made. The clinical manager undertakes a quarterly audit of medication practices and when one carried out in July 2009 identified some records were not signed, action was taken to rectify this and no further entries were unsigned. Controlled drugs are checked three times a day at shift changes. The file for one person showed the person had been assessed as being able to self medicate and was doing so. The other three files showed the people could not self medicate. We were told in the assessment they completed that ‘All staff are aware of each service users preferences and are always expected to treat service users with respect, manitaining their privacy & dignity at all times. Dignity in Care has been promoted in the work place by appointing a Dignity Champion’. There was information about Dignity in Care around the home and the manager said how staff are being trained and supported to become dignity champions within the home. The staff development manager has developed the information provided by the Local Authority into a staff training programme which all staff attend. One person commented, ‘I love the way that all the staff know my name’ and the manager said service users have been involved in developing Dignity in Care within the home through discussion and showed contributions some people had made in writing. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 14 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 who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in planning and meeting their social needs both in and out of the home and have opportunities to try new things as well as following interests they already have. EVIDENCE: We were told in the assessment they completed that, ‘There are six days a week where there is always something for the service users to take part in and once a week a piano player comes to provide entertainment. On top of this we always have external entertainers coming to the home on a regular basis. Cherry Holt has its own mini bus and trips to the theatre, museums and parks etc are arranged frequently’. A harpist was due to come to the home in the morning but had cancelled due to sickness and rearranged another date. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 15 Residents are able to take part in group and individual activities. There was a group listening to the daily story, completing a crossword and taking part in a quiz in the morning. Other residents were seen taking part in individual activities including drawing and reading. The activities coordinator showed some poems one person had written about her experiences moving into the home. There are two residents who assisit the activities coordinator in organising and running activity sessions, which enables her to increase the amount of individual activities provided to people confined in their rooms. The activity coordinator says she is always on the lookout for something new to try and has recently started evening card nights in addition to the themed evenings which already take place. There have also been barbeques organised in the good weather and the manager recently prepared a curry night. There is a weekly communion service held and some people go out to a local church. In our survey forms twelve people said there are activities arranged by the home they can take part in, and one person said there sometimes are. There were many positive comments made, including, ‘Provide a lot of stimulus through activities’, ‘I especially like the musical concerts that we have and I’d like to say how good the hairdresser is’ and ‘I like the fact we have musical concerts and that my granddaughter is allowed and invited into the home to play her keyboard, this is very important to me’. The activities coordinator was seen inviting relatives visiting the home to join in a trip out she was organising. There was a section within the file to record where anyone has a change of preference. One person had requested to have brown bread in future, which is being provided. In our survey forms nine people said staff listen and act on what they say, three people said they usually do and one person said they sometimes do. One person commented, ‘Staff listen and act on suggestions’ and another person said, “We just have to say what we want and they do it, they are wonderful”. We were told in the assessment they completed that, ‘Our menu is periodically changed to meet the preferences of our services users whom reside at Cherry Holt. An individual likes and dislikes page is kept in the kitchen so the catering staff know what each service user likes and dislikes. All special dietary needs are catered for’. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 16 The manager said he has spent a lot of time working on a menu that everyone is happy with. He said they have tried difrerent types of dishes, such as lasagne, but they have not been popular and he was now very happy the menu reflected people’s preferences. It is currently being extended from a four week to a five week menu. The daily menu is displayed in each dining room in pictoral form as well as a printed menu on each table. During a period of observation at lunchtime staff were assisting some people to eat their meals in a relaxed manner. There is a cooked breakfast provided every other day which alternates with the days there is a cooked tea provided. People choose their lunch during the morning, but sufficient is catered for to accommodate anyone who changes their mind. Comments made about the food included, “There is a choice every day about what we eat”, “We just have to say if we want something different like soup or a sandwich” and “The food is good and I get plenty of it”. People also commented they had enjoyed their lunch. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 17 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 are encouraged to raise any complaints so any worries can be sorted out. People will be safeguarded in the event of any allegation being made. EVIDENCE: The Complaints Procedure is displayed in the entrance foyer and in each bedroom. This had been recently updated and showed the home is now registered with the Care Quality Commission. We were told in the assessment they completed that, ‘All complaints are recorded both in the complaints book and each service users file with the outcome also recorded’. There is a record made of all formal complaints, one has been received since the last inspection about a possible leaking toilet. Although the plumber could not fine any evidence of a leak, the toilet was still replaced to provide peace of mind. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 18 The manager also asks people on a daily basis if they have any grumbles about anything, and a record is made of who has been asked, and if there were any grumbles what they are. Examples of issues raised were the parsnips were a little hard and a hot water tap was not working. The manager responded to all grumbles made. Staff spoke of sorting out any problems of daily living as they arise, such as occasions when an item of clothing has not come back from the laundry. In our survey forms ten people said they know how to make a complaint and three people said they did not. One person told us, “Just tell whoever and it gets to Rak (The manager) who comes to sort it out”. Staff were aware of the procedures to follow in the event of any allegation, including informing the Local Authority. In the assessment they completed we were told that, ‘Policies & Procedures are kept in the home with relation to complaints and the prevention of abuse. All staff are trained in the Safeguarding of service users.’ People commented that they felt perfectly safe in the home and that they are only treated with kindness. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 19 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained environment, which is clean, pleasant and hygienic EVIDENCE: We were told in the assessment they completed that, ‘Cherry Holt has two maintainance men employed on a full time basis. Any changes made to the environment always have the input of service users. Cherry Holt is a purpose built home with all 52 bedrooms having en suite facilities, there are sufficient bathrooms and toilets on top of this. Communal areas are all very spacious and all coridoors are wide. Service users are encouraged to personalise their rooms Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 20 in any way which they may want to do so’ and ‘Three cleaners are on shift everyday, we have a programme in place to ensure all carpets are cleaned and at least one bedroom is spring cleaned everyday. All staff undertake training in infection control, fire practices and health and safety. Cherry Holt has a full time gardener who ensures well kept garden areas for service users to enjoy and sit in’. In the minutes of a recent residents meeting people were aslked whether they liked the decorating and everyone said yes, with the comment ‘Bright fresh looking dining rooms’. Everwhere seen was clean, tidy and fresh in odour. In our survey forms twelve people said the home is always fresh and clean and one person said it usually is. Comments made included ‘Most important for me is cleanliness and this home is spotless. The bedding is always lovely which I really like’ and ‘Keep the place very clean and without smell often associated with such establishments’. Staff were seen using protective clothing when providing personal care and handling food. One person said the home is always spotless” and “They always put on aprons and gloves when they help me”. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 21 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. There are sufficient and suitably trained staff employed at the home, ensuring that residents needs can be met. Residents are supported and protected by the home’s recruitment policy and practices EVIDENCE: We were told in the assessment they completed that, ‘At Cherry Holt we strive to provide services users with an exellent mix of staff so we are able to meet all their needs. The Staff Development Manager ensures that all staff have undertaken mandatory training and undergo the Skills for Care Induction Programme. Staff are also encouraged to take part in further training and NVQ’s are being undertaken within the home at levels 2,3 & 4. We also deliver in-house training by the Staff Development Manager who has recently completed the Train the Trainers course in Mental Capacity and Safeguarding. Prior to any employment potential staff must complete an application form providing details of previous employment, two satisfactory references, POVA (Protection of Vulnerable Adults) check and a criminal Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 22 records check. Any discrepancies are invesitgated and a conclusion arrived at before employment commences’. Staff said the manager had made some changes how staff are deployed at busy times in response to them saying they were busy. One person told us, “The staff are so flexible, they will do anything for you”. Other people commented, ‘I am not lonely because staff are always calling in to talk and ask if I need anything’ and ‘I really love the night staff and all the carers are so kind’. A sample of two staff files were seen which contained the required pre employment checks which included an induction programme. Some staff said they had completed a professional qualification and others said they were working towards one. Information about staff completing courses is shared with residents. Staff were aware of training they have coming up, including on Deprivation of Liberty and Mental Capacity Act. The staff development manager showed the records of training undertaken by staff and what further training is planned. She also showed other initiatives and development opportunities being followed, including preparing an entry to submit to the care awards and taking part in a sharing best practice scheme. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 23 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have great confidence in the manager and there are suitable management systems in place for the smooth running of the home and to protect them. People are empowered to express their views on how the home is run. EVIDENCE: We were told in the assessment they completed that, ‘At Cherry Holt the Provider and the Manager are Father and Son respectively. We both share a Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 24 common goal as we operate a family business. The Registered Provider is a Qualified Nurse and the manager has a BA Hons in Business Aministration. The management has has an open style of management where we make ourselves available on a daily basis to encourage service user feedback and develop.’strong relations. Our open style management encourages all parties within the home to communicate with us at all times. The mangement also carry out internal audits, risk assessments and surveys, which we find a valuable tool to ensure service users live in a safe well maintained environment.’ Staff described the manager as very good and one resident said, “He is ever so good. Nothing is too much trouble”. Residents had requested the minutes of the residents meeting recorded, ‘A generous and caring manager and how special he made them feel as individuals. They said he was unique’. The home has recently maintained their Investors in People status and there is a quality assurance system in place. The results of this are made available in the home and discussed in the residents meeting. These showed a high level of satisfaction with the services provided. The assessment we ask the provider to complete and send back to us was returned on time. The infomation contained in this was detailed and included the views of people living there, and reflected what we saw during the visit’. The manager said he had spent a long time devising the menus in residents’ meetings which enabled people to put forward their likes and dislikes. One person told us, “We have residents meetings where Rak tells us things then we can have our say”. We were told in the assessment they completed that equipment is serviced or tested as recommended by the manufacturer or other regulatory body. Dates were provided showing this to be the case. Staff said they did not have any concerns about health and safety within the home. Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 25 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cherry Holt Care Home DS0000024634.V377210.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. 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