CARE HOMES FOR OLDER PEOPLE
Cherry Holt Care Home Welham Road Retford Nottinghamshire DN22 6TN Lead Inspector
Stephen Benson Key Unannounced Inspection 11th September 2006 9:30 X10015.doc Version 1.40 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 Cherry Holt Care Home DS0000024634.V309635.R02.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 Older People. 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. Cherry Holt Care Home DS0000024634.V309635.R02.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 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.V309635.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th February 2006 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. The home has achieved Investors in people status. Further information about the home can be found on its website at www.fbccarehomes.com. The manager said on 11/09/06 that the fees for the service range from £334 £358 per week depending on dependency needs. There are additional charges for dry cleaning, hairdressing and chiropody. Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2006 by The Commission for Social Care Inspection. The home has not had a resident under the physical disability category for over a year so the visit did not cover this. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 4 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the provider, the manager, the clinical manager, staff on duty and care practices were observed. No relatives were seen during the visit. 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:
A qualified nurse is employed as a clinical manager who has responsibility for ensuring residents’ healthcare needs are met. A record is made of every healthcare appointment ands these showed that regular appointments are taking place. Equipment was seen for meeting healthcare needs and residents said that their healthcare needs are well seen to. The evidence shows that residents’ health care needs are fully met. There is a designated room for storing medication in and records showed that residents were given their medication as required. Residents said staff make sure you take your medication. The evidence shows that residents are protected by the homes procedures for dealing with medicines Staff were aware of good practices when assisting residents with personal care to respect their privacy and dignity and were seen knocking on residents doors before going in. Residents said that staff are always respectful. The evidence shows that residents’ privacy and dignity are promoted. There is an activities coordinator employed in the home who ensures each resident takes part in at least one activity of their liking each week. There is a wide and varied choice of activities available. Residents said that there is always something going on. The evidence shows that resident’s lifestyle matches their expectations. The home has its own mini bus for trips out to local places of interest and there is information about the local community in the home. Residents said they are able to have visitors as they please. The evidence shows that residents maintain contact with family, friends and the local community. Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 6 Residents are free to move around the home as they choose and the manager asks residents what routine they would like. Residents said they can please themselves in the home. The evidence shows that residents have control over their lives. The complaints book had a record of recent complaints being dealt with appropriately and staff were aware of what to do with any complaint. Residents said they had been told to say if they had any problems. The evidence shows that residents are confident that their complaints will be listened to. The manager has used the Adult Protection Procedures following allegations made. Staff said abuse would not be tolerated and residents said they had never seen any mistreatment. The evidence shows that measures are in place to protect residents from abuse. The home is well laid out with plenty of communal space and wide corridors. There is a system for staff to report any repairs which need doing, and these are responded to quickly. The home is currently being decorated internally. Staff said that bathrooms and toilets are located where needed. Residents were happy with the home. The evidence shows that residents live in a safe, well-maintained environment. There are cleaning staff employed each day of the week and staff said that carpets in communal areas are cleaned at night time. All areas of the home seen during the visit were clean, tidy and fresh. The head cleaner checks the building to see if anywhere is in need of additional cleaning. Residents said everywhere is kept clean. The evidence shows that the home is clean, pleasant and hygienic. The rota shows the number of staff on duty each shift and there is always a nurse in charge on duty. One member of staff is available to work upstairs or downstairs depending on where is busier at the time. Residents said there always seem to be enough staff on duty. The evidence shows that residents’ needs are met by the numbers and skill mix of staff. The home employs qualified nurses, nurses from overseas who are going through an adaptation programme, so that they are able to use their qualifications to practice in this country and some care staff have completed National Vocational Qualification level 2. More are to start the course soon. The evidence shows that residents are in safe hands at all times. In addition to the registered manager the home employs a deputy manager, a clinical manager and the provider also assists in the running of the home. Staff think the home is well run and they feel supported in their job. The evidence shows that there is a suitable manager employed to run the home. The home will help residents with their personal allowances if wanted and a record is made of any expenditure made. This is signed by two people and receipts are kept where provided. The evidence shows that residents’ financial interests are being safeguarded. Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 7 Regular safety checks and tests are carried out and there are contracts in place for servicing equipment. The evidence shows that the health, safety and welfare of residents are protected. What has improved since the last inspection? 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. Cherry Holt Care Home DS0000024634.V309635.R02.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.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where they live. New residents are not fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: The manager showed a new brochure that has been prepared for the home and this is available to anyone enquiring about moving to the home. The provider said that he goes out to assess any prospective new resident with the clinical manager then discusses with the manager whether the residents needs can be met within the home. The manager said that further assessments are completed by the nurse on duty as part of the admission process and care plans are completed within 48 hours.
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 10 An assessment for a resident who was moving into the home later that day was seen, which was completed on the 6th September 2006. Due to the funding arrangements the resident was not assessed by Social Services. The home’s assessment was lacking in detail and did not include all the information staff needed to know, some of which was seen in the home’s diary. The manager received a faxed Community Care Assessment from Social services about a prospective resident during the inspection and said these are always obtained when residents are funded by Social Services as part of the assessment process. Staff said that they know in advance when a new resident is coming to the home and that assessments are available for them to read. A new resident was arriving that afternoon and staff said they had been aware that they were coming for several days. No residents spoken with could recall what happened when they were moved to the home. There is no arrangement made for the home to provide an intermediate care service. Cherry Holt Care Home DS0000024634.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social needs are set out in an individual plan of care. Residents’ health care needs are fully met. Residents are protected by the homes procedures for dealing with medicines. Residents are treated with respect and dignity. EVIDENCE: The manager said that he had reorganised care plans creating individual sections for each part of the plan, which had made them a lot quicker and easier to use. A sample of three care plans were looked at. They are kept in red or blue folders to identify whether a resident is assessed as needing residential or nursing care. Plans included assessments, risk assessments as well as individual plans of care. There was a brief social history and details of residents’ hobbies and interests. Plans were being reviewed each month and there was a form for showing residents and or their relatives have seen the
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 12 plan. The manager said that this was something new he was implementing and was still waiting to see some relatives. Plans seen provided clear detail of the care to be provided, for example stating the type of handling belt to be used when helping a resident to stand up, and they referred to maintaining resident’s independence. There is a section to record daily notes about residents well being. Staff said that care plans are useful for providing them with information and they use them to help with their work. A resident said “I don’t remember being told about a care plan but I am happy with the care I get” and another resident said “I don’t need any help in getting up I want to be as independent as I can”. The clinical manager, who is responsible for ensuring residents’ healthcare needs are attended to, said that residents see any healthcare professional that they need. The clinical manager said that district nurses come to see to residents who are not assessed as needing nursing care and that they are working with the tissue viability nurse for two residents who are at risk of pressure sores. There was appropriate pressure relieving equipment seen in use around the home. There is a section in the care plan to record all contact had with healthcare professionals. These showed that residents’ physical and mental heath are monitored and there were dates seen for recent healthcare appointments. Residents weight is monitored and two residents admitted to the home within the last year had increased their weight after admission. Staff were seen following good and practices when helping resident with their mobility by using the correct equipment and using footplates on wheelchairs. A resident said “if you need a doctor they get you one, and you can keep your own doctor. If anything is not right you just tell the nurse and she will sort anything out”. Another resident said “staff are so patient when they help me, I don’t deserve it as I don’t do what they tell me to making it more difficult for them”. The arrangements for managing residents, medication were well managed. There is a designated medical room where medication is appropriately stored. All Medicine Administration records were fully completed and there is a system in place to deal with any gap found. Any changes made included details of who had made these and were cross-referenced in the care plan. The clinical manager praised staff for their diligence in following the correct practices. All creams and lotions are dated when opened and where required stored in a fridge. The Controlled Drugs register was correctly filled in and a sample of tablets were checked and found to be correct. A resident said “staff bring round tablets and watch you take them to make sure you have had them”. Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 13 The manager said that he expected staff to respect residents’ privacy and dignity and this is included as part of the induction for new staff. The manager said he expected staff to know each resident’s preferences. Staff described good practices in respecting residents’ privacy and dignity when providing them with personal care. This included the use of towels and sheets to cover residents when using a bath and only providing the level of assistance required, letting the resident do s much for themselves as they are able. Staff said they train up new staff in good practices as part of their induction. Staff were seen knocking on residents doors before entering their room. A resident said “I don’t have a key for my room, I don’t think it would be allowed, but when I went to hospital my room was locked while I was away”. Another resident said, “Staff help me, they are always respectful, everyone will agree with that. I don’t know how they can be so nice all the time”. Cherry Holt Care Home DS0000024634.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations and there are excellent entertainment opportunities. Residents maintain contact with family and friends and the local community. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome and balanced diet. EVIDENCE: The home employs an activities coordinator who is responsible for arranging activities within the home. The activities coordinator said that she is expected to provide each resident with at least one activity a week. There is an activities folder, which has photos of past activities, a list of activities available, a record of who has taken part in which activity and comments about how the activity had been received. There were notices around the home showing what was happening that week. The activities coordinator said that she has several activities taking place at any one time, and finds that there is always something a resident will enjoy if they don’t want to take part in one of the organised games, such as having a
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 15 massage or reading a book. The activities coordinator said that she is well supported in her role by management and other staff. There were many examples of interesting, varied and entertaining activities provided, including container gardening, a book club, video library (a film can be played on the video that can be received in every resident’s room), a visiting pianist, wine and sloe vodka making, and a game of the television show “What’s My Line”, which is sometimes used to introduce new residents. The activities coordinator was seen encouraging residents to join in the morning activity of guessing what old cookery object was wrapped in a cloth bag. This led to residents telling others about things they used to cook and remembering the “old days”. The activities coordinator was also asking residents who wanted to go on a visit to a local exhibition. A hairdresser comes to the home twice a week and there is a monthly communion service. Residents said that they play dominoes, do crosswords, watch videos and today had to guess objects in a bag. Residents also said they had enjoyed a recent gala day. One resident said “we do lots of different things, there is always something going on. They keep your brain working, which is good for us”. The activities coordinator showed great enthusiasm for her role and she ensured that everything was in place for the activities programme to continue whilst she was off work recently recovering from an operation. The activities coordinator said that she regularly organises trips out of the home, including the local theatre, shops, garden centres, cafes and parks. The home has its own mini bus to take residents out. Staff said that visitors are always welcome to come and spend time with residents in one of the lounges or in their room and that they can go out somewhere if they want to. A resident said “I am going to a Gilbert and Sullivan concert tomorrow night” and “I go out for lunches and we have loads of visitors come”. The manager said that he asks residents what they would prefer their daily routine to be and he passes this onto staff. Staff said that residents are able to do as they wish and can get up and go to bed as they choose. Some residents don’t go to bed until 11.00pm and others at 6.30pm. Residents were seen using different areas of the home. Some residents were taking part in an organised activity and others were watching a James Bond video and some chose to be in their own room. Residents said “you can please yourself here, you are not forced to do anything” and “you are not given a timetable, I have been told there are no fixed times”
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 16 The manager has prepared a new menu, which has introduced some new dishes, including chicken in white wine sauce and sweet and sour pork. The manager said that residents had asked for the chicken in white wine sauce to be more frequent which has been done. The menu does not offer a choice of meal but there is an alternative available if wanted. Staff said that they thought the food was good and if they see a resident doesn’t like something the will tell the kitchen staff so they can be given something else. There were differing comments received from residents about the food, some saying they thought it was “good”, others said it was “sometimes ok and other times not”. Comments were also made about meat being tough and vegetables overcooked. Cherry Holt Care Home DS0000024634.V309635.R02.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to. Measures are in place to protect residents from abuse. EVIDENCE: The home has a complaints procedure and there is a central book to record any complaints in. There were two entries since the last inspection from a relative about the care they received. The relative met with the provider to discuss this and was satisfied with the outcome. The provider said it had been a case of helping the relative see what the home was and was not able to do. Staff said they pass on any complaints to the nurse in charge, and if they can deal with anything they will do. Staff said that they don’t hear many complaints. there was a time when washing was getting mixed up but that has improved now. A resident said “I was told when I first came here to tell someone if I had any problems. They are very good like that.” The manager has dealt with two allegations of abuse since the last inspection. One allegation was that the hairdresser was overcharging some residents. This was correctly reported to The Adult Protection Unit, The Police and the Commission for Social Care Inspection. The home refunded all monies overcharged, changed the payment system and bought in another hairdresser.
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 18 The second allegation was that a member of staff had shouted at residents and was subsequently dismissed. Staff said there is no mistreatment in the home, it is like one big family. A resident said “I have never seen any mistreatment here, I would be one of the first to shout out if that was the case”. Cherry Holt Care Home DS0000024634.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home is purpose built and well laid out with lounge and dining areas on both floors. The top floor has almost finished being redecorated throughout and the manager said the ground floor will be done shortly. The home is well laid out and has wide corridors and everywhere is accessible to wheelchair users. Staff said they think the building works well, there are sufficient toilets and bathrooms, which are large enough and conveniently located near lounges and dining rooms. Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 20 There are two maintenance men employed who carry out routine repairs and decorating. There is a repairs book for staff to report any maintenance needed and this showed that repairs are promptly dealt with. A resident said the home is lovely and I am going to ask for a shelf to be put up in my room so I can put on my ornaments”. There are three domestic staff on duty each day and they were seen cleaning various areas of the home during the visit. The manager said that the head cleaner is allocated time to check the building to see what needs to be done. Staff said that the home is kept spotless and carpets are cleaned at night time. A resident said “my room is cleaned everyday and everywhere is kept brilliantly clean”. Cherry Holt Care Home DS0000024634.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. Staff are not fully trained to do their jobs. EVIDENCE: The home employs nursing, care, kitchen, domestic, laundry and maintenance staff, with additional support from a deputy manager and an activities coordinator. There is one nurse on every shift and six carers on during the day (with an additional one between the hours of 7am – 10am), and a nurse and four carers at night. The manager said that there are three staff on each floor during the day with one member of staff floating depending upon where the greatest need is. Staff said that there were times when an extra pair of hands on the top floor would be useful in the mornings so they could attend to residents more promptly. A resident said “there always seems to be enough staff on duty”.
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 22 There are three care staff who have completed National Vocational Qualification level 2 and three more are due to start shortly. Two staff are about to start National Vocational Qualification level 3. In addition to the qualified nurses the home employs six adaptation nurses. Staff files seen showed that the correct recruitment practices are followed, although one file, whilst having two satisfactory references, did not have one from the most recent employer, which was another care home. There were files made up for a new group of adaptation nurses to come to work in the home, who are waiting for Criminal Records Bureau checks to be returned before they start work. The manager showed a file of staff training certificates and a training plan. This showed that staff have not done all of the mandatory training required Staff said that they take parting any courses available. A resident said “staff are very good at what they do”. Cherry Holt Care Home DS0000024634.V309635.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable manager employed to run the home and there is additional management support. Residents are not expressing their views on how the home is run. Residents’ financial interests are being safeguarded. The health, safety and welfare of residents are protected. EVIDENCE: A new manager was registered for the home in March 2006, who is the son of the providers. The manager has worked in the home for 10 years, mainly in an administrative and managerial capacity, but has also been involved in providing care. The manager is currently working towards achieving National Vocational Qualification level 4 and has a BA (Hons) in business administration,
Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 24 a BTECH Higher National Diploma in Business and Personnel and an advanced GNVQ in Business. In addition the home employs a deputy manager and a clinical manager. The provider is actively involved in the running of the home and is there most days. Staff thought the home was very well run and that if they need anything for their work they only have to ask. Staff said the manager and provider are very approachable and will do what they can to help you. The deputy manager carried out an audit in July 2006 and a further one is planned for January 2007. The audit record was seen and where any shortfall was identified an action plan was prepared to address this. There was a survey about the home in the entrance area for residents and relatives to complete but none of these have been retuned recently. The provider is not completing monthly Regulation 26 reports, which he is required to do. The home will hold money for residents to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction and signed and witnessed. Receipts are kept when available. The manager said that all the required health and safety checks and tests are being carried out at the required frequencies and there are service contracts in place for all equipment and the lift. A resident said “they tell you when they are going to test the fire alarm”. Cherry Holt Care Home DS0000024634.V309635.R02.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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 x X 3 X 3 Cherry Holt Care Home DS0000024634.V309635.R02.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. 1 2 3 Standard OP3 OP30 OP33 Regulation 14 18 26 Requirement The registered person must ensure that new residents are fully assessed prior to admission The registered person must ensure staff have undergone all mandatory training The registered person must undertake Regulation 26 visits and ensure the views of residents are included Timescale for action 01/10/07 01/02/07 01/10/06 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 3 Refer to Standard OP10 OP15 OP29 Good Practice Recommendations The registered person should provide residents with a key to their room if thy are assessed as being able to use one The registered person should provide a choice of main meal on the menu The registered person should take up references from applicants most recent employment Cherry Holt Care Home DS0000024634.V309635.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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