This inspection was carried out on 16th August 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Cherry Holt Care Home Welham Road Retford Nottinghamshire DN22 6TN Lead Inspector
Stephen Benson Unannounced 16/8/05 9.30am 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 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 C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Cherry Holt Care Home Address Welham Road Retford Nottinghamshire DN22 6TN 01777 710347 01777 710499 rak@fbccarehomes.com Mr K Sooriah Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Diane Brett CRH 52 Category(ies) of OP 52 registration, with number PD 3 of places Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30/03/05 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 home’s 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 Since the last inspection the home has achieved Investors in people status. Further information about the home can be found on its website at www.fbccarehomes.com. Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the first of two unannounced inspections to be carried out between April 2005 and March 2006. The inspection lasted for 4 hours and the main method of inspection used was called case tracking which involved selecting 3 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 and care staff on duty. Care practices were observed. No relatives or other visitors were spoken with. 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: What has improved since the last inspection? What they could do better:
Arrangements need to be in place to ensure that privately funded residents are assessed before they move into the home to ensure that their needs can be met. When an assessment has been carried out this must be used to prepare a plan of care for meeting the resident’s needs. Details of personal care to be provided should also be in the care plan. Residents said they were happy with the help and support they get. A record should be made in the care plan of residents preferred funeral arrangements.
Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 6 The recruitment procedures should be correctly and fully used in the recruitment of all staff and there needs to be a full record of training undertaken by staff. The current management arrangements need some clarification due to the number of people involved in the day to day management of the home. 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 C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 More attention is needed to ensure that a written assessment is in place prior to admission and this is used to prepare care plans. EVIDENCE: There were community care assessments in place for residents who are funded through community care arrangements. The system for assessing residents who are privately funded was not being fully operated. One recently admitted resident had not been assessed and another due to be admitted shortly had been visited, but the notes made had not been written up into an assessment. Where assessments were in place some care plans were being given to nurses on an adaptation programme to write up, but these were not being prepared promptly and in one case a resident was being discharged before a care plan had been written. Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 10 and 11 Residents are happy with the personal care they receive but this is not being fully recorded. EVIDENCE: There were no details in some care plans seen as to what assistance with personal care residents need, although one of the residents described the support she receives and said she was very happy with the way any help is provided. Other residents said that staff are sensitive when providing personal assistance and they respect their privacy and dignity. Staff spoken with said that they had been given guidance on how to treat residents with respect. Residents are able to spend their final days at the home if they wish and community support services are accessed to enable this. Only a few care plans had residents preferred funeral arrangements recorded in. Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 10 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 standard(s) None EVIDENCE: Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 16 and 18 Residents concerns are acted upon and they are protected from abuse. EVIDENCE: The home has a complaints procedure and a book to record any complaints in. It is expected that any complaint is recorded, although in practice only those deemed to be of a serious nature are written into the complaints book. Residents said that staff always sorted any problem out and they did not have any complaints. Staff were aware of the adult protection procedures and a copy of these were in the main office. The manager said that there has not been any incident of abuse and residents said that nothing like that would ever happen here as staff always treat residents with respect and show great patience. Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 12 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 standard(s) None EVIDENCE: Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home is suitably staffed but recruitment processes are not being applied rigorously enough. Training records do not show what training is being undertaken by staff. EVIDENCE: The provider has arranged for nurses from overseas to undergo adaptation training within the home and they are included within the staff compliment. There is a rota showing staff on duty that includes a qualified nurse on at all times. There is additional ancillary support with maintenance, kitchen and domestic staff being employed. Residents said that they felt there were enough staff on duty. The process for recruiting new staff includes completing an application form and health check, undergoing an interview, taking up references and undergoing a Criminal Records Bureau check. Files seen for recently appointed staff did not fully comply with this process, as they did not have a full work history, references from the previous employer were not sought and a Criminal Records Bureau check bought by a member of staff from her previous employment was over 12 months old. The administrator has produced a new application form, which is to be implemented shortly. Adaptation nurses are recruited through agencies the home has developed links with, however they must also undertake a check against the POVA (Protection of Vulnerable Adults) register. Staff spoken with said that they receive regular training including NVQ training; however training records did not show which training staff have
Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 14 undergone and what training staff require. Adaptation nurses are provided with additional supervision and training. Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35 Management arrangements need to be clarified. Residents are able to comment on services provided. EVIDENCE: The provider is actively involved in the day to day running of the home and other members of his family also take on aspects of managing the home. This left an unclear picture as to the role of the registered manager. The home has recently gained Investors in People status. Questionnaires about services provided are displayed in the hall with a box for them to be returned in. A copy of The Commission for Social Care inspection report is displayed in the entrance. The manager said that residents meetings have been suggested to residents but no interest was shown. Residents said they make comments on the services provided to staff. Residents or their relatives look after their finances. Small sums of money are held to pay the hairdresser and all other expenditure is managed directly by the resident or their relative.
Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 16 Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 2 3 x 3 x x x Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement Ensure that new residents are asessed prior to admission and that care plans are prepared from this Ensure that a record is made in the care plan of personal care required Include in care plans residents preferred funeral arrangements Ensure that correct recruitment processes are adhered to Keep a record of all traning undertaken by staff Clarify the management arrangements for the home Timescale for action 1st October 2005 1st November 2005 1st November 2005 1st October 2005 1st November 2005 1st November 2005 2. 3. 4. 5. 6. 10 11 29 30 32 12 12 19 18 10 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Cherry Holt Care Home C03 C53 S24634 Cherry Holt V244016 160805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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