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Inspection on 20/07/06 for Cherwood House Care Centre

Also see our care home review for Cherwood House Care Centre for more information

This inspection was carried out on 20th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is very well managed by the senior management. The residents are the focus for everything that happens at the home, and each resident is treated as an individual.Visitors are always made very welcome and relatives are encouraged to be involved in the life of the home. A comment from a relative/visitor in the Commission`s comment card said "This is an exceptionally good and caring home, treating family as team members. There is good physical care and staff are loving towards their residents; patient and imaginative". The activities programme is excellent, and allows the opportunity for residents to choose what they would like to take part in. Meals and mealtimes are one of the highlights of the day at Cherwood.

What has improved since the last inspection?

The redecoration and refurbishment of the entrance hall and dining room is nearing completion. Risk assessments have been carried out for all areas where radiators are not covered, and new covers have been obtained ready for fitting. The flooring in the toilet adjacent to the day room in the nursing wing has been made good.

What the care home could do better:

The recruitment process needs to be firmed up to ensure that new staff do not commence duties until satisfactory written references have been obtained, and the protection of vulnerable adults first check has been made. The bathrooms in the nursing wing are in a very poor state and require refurbishment so that the residents who use the bathrooms may bathe in comfortable pleasant surroundings.All care plans need to be reviewed monthly to ensure that the individual`s care needs are met. Where two individuals occupy a shared room it is important to assess how the individual`s privacy and dignity will be maintained. The hairdressing chair is in need of replacing or re-covering with a fabric that is easily cleaned. A laundry basket for soiled towels awaiting being laundered needs to be provided.

CARE HOMES FOR OLDER PEOPLE Cherwood House Care Centre Buckingham Road Caversfield Bicester Oxfordshire OX27 8RA Lead Inspector Philippa MacMahon Unannounced Inspection 20th & 24th July 2006 07.10 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 Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherwood House Care Centre Address Buckingham Road Caversfield Bicester Oxfordshire OX27 8RA 01869 245005 018869 324844 yvonne.cherwood@cherwoodhouse.co.uk 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) Ellenbern Holdings Limited Yvonne Bazylkiewicz Mrs Lynda Joy Anders Care Home 103 Category(ies) of Past or present alcohol dependence (3), registration, with number Dementia (35), Dementia - over 65 years of age of places (35), Learning disability (4), Learning disability over 65 years of age (4), Mental disorder, excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (103), Physical disability (12), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (2), Terminally ill over 65 years of age (10) Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of service users must not exceed 103 The lower age limit for admission to the PD, A, LD, DE and MD categories is 40 years. Older people requiring nursing care may be admitted from age 60. Categories of Residence: The following numbers must be observed when admitting service users: OP DE and DE(E) MD and MD(E) PD PD(E) LD and LD(E) A TI(E) SI(E) Date of last inspection Nursing places limited to 58 Nursing places limited to 25 Nursing places limited to 4 Nursing places limited to 6 No nursing places Nursing places limited to 2 Nursing places limited to 1 Nursing places limited to 8 No nursing places 30th January 2006 Brief Description of the Service: Cherwood House is part of Cherwood House Care Centre, situated close to Bicester in the Oxfordshire countryside. It is a family owned business, registered with the Commission for Social Care Inspection (CSCI) to provide nursing and residential care in Cherwood House. The cottages within the grounds at Cherwood Close are not regulated by CSCI. This report only refers to the nursing and residential services provided at Cherwood House. Cherwood House is a substantial house that was originally a Royal Airforce Officers Mess, and carries with it a lot of history and the original timbers in the bar tell their own story. The house has been extensively extended over time and now provides nursing and residential care for up to 103 residents. The nursing and residential wings are separated by the spacious shared entrance hall, which also serves as a comfortable meeting area for residents, relatives and friends. The accommodation is provided over two floors in single or double rooms, Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 5 some with en-suite facilities. There is a passenger lift in each wing, and ramps provided to allow wheelchair access throughout the home. The communal areas include spacious lounges, and dining rooms in each wing, and the bar is open to all residents at arranged times. The extensive grounds are accessible to all residents and include raised beds, a greenhouse, and a safe area suitable for vulnerable people. The fees for this service range from £409 to £817 per week. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 07:10 hours on the first day and was in the service for a total of 13 hours over the two days. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined and this was followed up by meeting with individuals to ensure that their care needs were being met. The medication systems were examined. A tour of the buildings and grounds was made. Staff rosters, recruitment procedures, and training and development programmes were examined. The inspector spent some time talking with residents, relatives, visitors, and staff. Discussion also took place with the registered provider, and the two registered managers. Records required by regulation were examined. The inspector would like to thank all who contributed to this inspection in any way. What the service does well: The home is very well managed by the senior management. The residents are the focus for everything that happens at the home, and each resident is treated as an individual. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 7 Visitors are always made very welcome and relatives are encouraged to be involved in the life of the home. A comment from a relative/visitor in the Commission’s comment card said “This is an exceptionally good and caring home, treating family as team members. There is good physical care and staff are loving towards their residents; patient and imaginative”. The activities programme is excellent, and allows the opportunity for residents to choose what they would like to take part in. Meals and mealtimes are one of the highlights of the day at Cherwood. What has improved since the last inspection? What they could do better: The recruitment process needs to be firmed up to ensure that new staff do not commence duties until satisfactory written references have been obtained, and the protection of vulnerable adults first check has been made. The bathrooms in the nursing wing are in a very poor state and require refurbishment so that the residents who use the bathrooms may bathe in comfortable pleasant surroundings. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 8 All care plans need to be reviewed monthly to ensure that the individual’s care needs are met. Where two individuals occupy a shared room it is important to assess how the individual’s privacy and dignity will be maintained. The hairdressing chair is in need of replacing or re-covering with a fabric that is easily cleaned. A laundry basket for soiled towels awaiting being laundered needs to be provided. 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. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 9 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 Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 10 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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every resident is given the information they require prior to being admitted and has a full assessment of their care needs. The home does not provide an intermediate care service. EVIDENCE: In the sample of care plans examined each was based on a thorough assessment of care needs prior to the person being admitted to the home. The Service User Guide was examined and found to be up to date and reflects the service provided. Every prospective resident is given a copy of this. Cherwood House Care Centre DS0000027144.V304159.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Every resident has a care plan in which their assessed care needs are identified and the action required to meet those needs. The residents have ready access to other health care services in order that the assessed needs are met. Medication systems are good. The residents are treated with dignity and respect. EVIDENCE: A sample of care plans was examined in both the nursing and residential wings. These were found to be comprehensive and reflected the residents’ individual care needs, including their social and recreational needs. Risk assessments are carried out and recorded in the care plan with regular updates shown. The daily record in both wings contains information that needs to be transferred onto the care plan so that the appropriate action is maintained. In particular, wound care needs to be monitored to ensure that the wound is responding to the treatment, and to clearly show when the wound is healed. Catheter care including the type, and size of catheter needs also to be clearly stated in the care plan. In the residential wing none of the Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 12 sample of care plans seen had been reviewed. The National Minimum Standards state “care plans should be reviewed at least once a month, updated to reflect changing needs”. It is recommended that all care plans should be updated at least once a month. There is good evidence of very good working relationships with the GP and District Nursing team. In the residential wing the District nurses leave their care plans in the home and there is excellent communication between the staff. The District nurse also provides teaching sessions on specific care issues, which is commendable. GPs visit the home on a regular basis and are readily accessible. Other health care professionals such as community psychiatric nurses, tissue viability nurses, and infection control nurses are readily available. The home has the services of a state registered physiotherapist who is available in the home on 4 days in the week. The physiotherapist is not employed by the home and works on a private basis. The medication systems in both wings were examined and found to be in good order and supported by appropriate policies and procedures, and the supplying pharmacist. The inspector observed staff assisting the residents in an appropriate and respectful manner, speaking to them by name and always knocking on the door before entering their private rooms. The inspector observed in one of the shared rooms that there were screens available to maintain the resident’s privacy and dignity when carrying out personal care. However, one of the residents in this room was able to provide a limited amount of care herself but was unable to move the screen into position. It is recommended that where rooms are shared that staff should assess how they can maintain the privacy and dignity of each resident in that room at all times and put in place the appropriate safeguards. Residents and relatives spoken to spoke very highly of the care provided and said “the staff are wonderful nothing is too much trouble”. Another relative completed the relatives comment card provided by the Commission and said “I think my father has wonderful care the staff are really great and my father has been really well since he has been in Cherwood”. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is ample opportunity provided for residents to enjoy social and recreational interest, and to follow their religious and cultural beliefs. Meals and mealtimes are very important to the residents and much enjoyed. EVIDENCE: Within the care plans examined there was evidence of personal histories having been obtained which contained good information to assist the staff in planning activities to meet the needs of the residents. The activities coordinator was seen to be interacting with the residents on the nursing wing, and the plan of activities was clearly displayed on the notice board. This plan was very clearly laid out with pictures in colour illustrating the various activities. Individual copies of the plan of activities are given to each resident so that they are able to look at it at their leisure and decide what they wish to take part in. The activities plan is varied and includes outings, trips, games, gardening and reading of the daily papers. There were numerous visitors to the home during the two days of inspection and they were all made to feel very welcome and those spoken to expressed that they always felt comfortable, and enjoyed their visits to Cherwood. Spiritual and cultural needs are also considered when assessing individual peoples needs, and a lay Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 14 minister from the local church visits the home twice a week and will meet with any of the residents if they wish, and particularly new residents. There are services of Holy Communion and songs of praise provided in the home, by the local Anglican Church, and the Roman Catholic priest also provides Holy Communion for those individuals requesting it. The registered manager informed the inspector that a prospective resident is due to be admitted shortly who is a foreign national and has a number of cultural needs that will need to be fulfilled. The registered manager is confident that they will be able to provide a service to meet the person’s needs. The main meal of the day is taken at lunchtime and residents spoken to really enjoyed the food and said that they always had a choice of main course, and found this difficult, as it is all so good! The spacious dining room is in the process of being refurbished and other various locations have been found for the residents to sit and eat their meals. The residents spoken to are really missing the social aspects of being all together in the dining room, but looking forward to the completed work. The dining room on the nursing wing is well laid out and provides a pleasant relaxed atmosphere for those residents using it. The meals served on both days of the inspection were seen to be in accordance with the planned menu, appealing and appetising. Catering staff spoken to expressed how the residents seemed to really enjoy their food and often offered suggestions, and comments which makes their job more interesting and challenging! On the first day of inspection the weather was really very warm by breakfast time and one of the residents requested a full cooked breakfast, which was duly presented, and much enjoyed. Seasonal changes are made to the menus and in the present “heat wave” a lot of salads had been requested, and ice cold drinks, and desserts are readily available. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is in place and accessible to residents, relatives/visitors. The registered managers make every best endeavour to ensure the residents are protected from abuse. EVIDENCE: The complaints procedure is posted on the main notice board, and is an appendix to the Service Users Guide. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The training plan showed that all staff receive training in issues about the protection of vulnerable adults. Staff spoken to were aware of these issues. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 16 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): 19,20,21,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home provides a comfortable homely environment that is maintained to a reasonable standard. Work is in progress to carry out major refurbishment and improvements. The bathrooms in the old wing of the nursing unit are in a poor condition. EVIDENCE: The inspector toured the buildings and the grounds, and overall found them to be in good order. The grounds looked particularly attractive with some raised beds that the residents tend, tomato plants, and extensive lawns that are all accessible to residents and their visitors. At the time of the inspection work was being carried out to redecorate the main entrance hall, and the main dining room. Re-carpeting of various areas is also being undertaken and the inspector met with the contractor who is carrying out this work and the remedial work required to the steps in the laundry. This work is due to be completed by the end of the week of this inspection. The registered provider Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 17 has agreed to write to the inspector informing her of the completion of this work. Radiator covers are to be installed and risk assessments have been carried out until such time as the work is completed. The hairdressing salon was found to be generally clean and tidy apart from the chair that is covered in a woven fabric and was covered in hair cuttings. The hairdresser was busy working and used towels were piled in a heap on the floor. It is recommended that consideration should be made into either replacing or covering the hairdressing chair, and to providing a suitable bin for the towels to be placed in prior to them going to the laundry. The communal rooms were found to be well laid out and provide comfortable, homely areas for the residents to enjoy. On both days these rooms were all well used and enjoyed by residents, their relatives and friends. In the nursing wing the bathrooms and toilets in the old wing remain in a very poor condition. These rooms have been in need of refurbishment for a number of years, with flooring that is broken, and toilets with seats that the finish has come off making it difficult to clean and they look unsightly. Both of these areas were cluttered with old equipment, a large cardboard box on the floor with coat hangers in it, and clearly not looked at from the perspective of a resident having a relaxing and enjoyable bath. Further discussion with the registered provider took place and he told the inspector that work is due to start on these areas within the next few months. It is recommended that the toilet seats in the bathrooms of the old wing should be replaced as soon as possible until such time as the refurbishment takes place, and the clutter removed. It is further recommended that the inspector should be notified of the completion of this work. The sluice in the nursing new wing was found to have a large number of clean commode buckets piled on the floor. This is not good practice and it is recommended that suitable shelving should be provided in the sluice in order that clean commode buckets can be properly stored. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers and skill mix of staff on duty at all times. The recruitment process needs to be tightened up to ensure that all checks are made prior to new staff commencing duties. Training and development opportunities for staff are good. EVIDENCE: Staff rosters examined showed that sufficient numbers and skill mix of staff are on duty at all times. The registered managers have both been proactive in ensuring that the staffing levels are adequate at times of most need. A sample of staff files was examined and apart from one was found to be in good order with all necessary checks in place. A new member of staff had commenced duties without obtaining two written references, (verbal ones had been obtained), and not having had the Protection of Vulnerable Adults (POVA) First check cleared prior to the Criminal Records Bureau clearance being obtained. This is not good practice and it is a requirement that all new staff must not commence duties until such time as a full recruitment process has been completed, including two written references having been obtained, the Criminal Records Bureau check has been applied for and the Protection of Vulnerable Adults First check carried out. The registered manager told the inspector that this person would not be working unsupervised until clearance is obtained and the written references obtained. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 19 There is a real commitment to staff training and development, and training coordinators in both units have developed training plans, and keep individual staff records up to date. The trained nurses have access to local training for nurses in the care home sector, and the programme covers relevant up to date issues. The induction programme in place is excellent and covers all necessary areas and leads well into the National Vocational Qualification level 2 for care assistants. Good progress is being made into attaining the target of 50 of all care staff having achieved National Vocational Qualification level 2 or above in care. Staff spoken to say that they had plenty of opportunity to develop and that all the staff understand that they need to be trained, and that it is good that the home is so supportive in this. Staff said “it is good for the residents that we do things right”. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 20 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): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by the registered provider, and the two registered managers, who provide an excellent senior management team. The administrative systems are robust. The health and safety of residents and staff are as far as possible promoted and protected. EVIDENCE: The two registered managers are both very experienced, qualified, and have excellent leadership skills. There is a strong feeling of good teamwork and a committed, caring work force. This is supported by the many complimentary comments contained in the 15 relatives/visitors comment cards and 18 “Have Your Say about Cherwood House” provided by the Commission that were returned prior to this inspection. One of the GPs who visits the home said in the GP comment card “excellent care provided”. Other health care Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 21 professionals also responded to the Commission with positive comments. The registered provider works in the home at least 5 days a week and meets with residents and staff on a daily basis. Relatives commented on his commitment and leadership in the Commission’s relatives/visitors comment cards. The management team is very strong. Quality systems are being developed in the home with regular residents and staff meetings, quality assurance questionnaires and regular audits of various aspects of the service provision, and both of the registered managers have an “open door” style of management being accessible to all staff, residents, and relatives at any time. The quarterly newsletters are much appreciated and offer a useful way to give feedback following the meetings and audits. Documents about servicing of equipment were examined and found to be up to date, and the insurance cover for the home is in place and the most recent certificate had just been received and was shown to the inspector. Staff receive mandatory training in fire safety, moving and handling, and food handling on a regular basis, and there is always a member of staff with a current first aid qualification on duty at all times. Fire training had taken place in January 2006, and the registered provider told the inspector that another session had not yet been planned. It is recommended that fire training should be planned bi-annually so that the two sessions are provided within the year. The home’s financial systems and safeguarding of residents’ personal cash were discussed with the financial administrator and found to be robust and in good order. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 2 Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 23 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 Standard OP29 Regulation 19(4)(b) (i) Requirement It is a requirement that all new staff must not commence duties until such time as a full recruitment process has been completed, including two written references having been obtained, the Criminal Records Bureau check has been applied for and the Protection of Vulnerable Adults (POVA) First check carried out. Timescale for action 21/08/06 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 Refer to Standard OP7 OP10 Good Practice Recommendations It is recommended that all care plans should be updated at least once a month. It is recommended that where rooms are shared, that staff should assess how they can maintain the privacy and dignity of each resident in that room at all times and put in place the appropriate safeguards. DS0000027144.V304159.R01.S.doc Version 5.2 Page 24 Cherwood House Care Centre 3 OP21 4 OP26 5 OP38 It is recommended that the toilet seats in the bathrooms of the old wing should be replaced as soon as possible until such time as the refurbishment takes place, and the clutter removed. It is further recommended that the inspector should be notified of the completion of this work. It is recommended that consideration should be made to either replacing or covering the hairdressing chair, and to providing a suitable bin for the towels to be placed in prior to them going to the laundry. It is recommended that fire training should be planned biannually so that the two sessions are provided within the year. Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cherwood House Care Centre DS0000027144.V304159.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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