Inspection on 30/01/06 for Cherwood House Care Centre

This inspection was carried out on 30th January 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.

Other inspections for this house

Cherwood House Care Centre 20/07/06

Cherwood House Care Centre 12/10/05

Cherwood House Care Centre 11/02/05

Cherwood House Care Centre 28/05/04

Cherwood House Care Centre 04/03/04

Similar services:

Flint House

Hillview Farm

St Vincents

Dalewood Respite Care

Orchard,The

Heather House Nursing Home

REACH Upton Court Road

The Cotswold Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cherwood House Care Centre Buckingham Road Caversfield Bicester Oxfordshire OX27 8RA Lead Inspector Philippa MacMahon 2nd Inspector Kate Harrison Announced Inspection 30th January 2006 09:40 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.V270979.R01.S.doc Version 5.1 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.V270979.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cherwood House Care Centre Address Buckingham Road Caversfield Bicester Oxfordshire OX27 8RA 01869 245005 018869 324844 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 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.V270979.R01.S.doc Version 5.1 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 12th October 2005 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.V270979.R01.S.doc Version 5.1 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. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the second inspection in the year. The inspectors were given a warm welcome and all cooperation was given by all of the staff present. As the home is managed as two separate areas and has two registered managers the inspection and this report is as one unit. The inspectors met with residents, visitors, and staff, toured the building, and examined documentation required by regulation. The inspectors received the pre-inspection questionnaires, and a number of comment cards from visiting professionals, and relatives and these were included in this inspection. What the service does well: What has improved since the last inspection? The induction and foundation training for new staff has recently been improved. Better nutritional screening is available. Training on falls prevention has been provided. The care planning system has been improved. More outings have been provided, including a trip to the seaside. A new plasma TV has been provided in the lounge of the residential wing. The manager is now able to organise transport for residents’ hospital appointments directly. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 7 Staff are able to spend more allocated time with residents if they do not want to take part in activities. The home has a new cat! 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. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 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 Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 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): None of these outcomes were inspected on this occasion as they were dealt with at the previous inspection earlier in the inspection year. EVIDENCE: Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. All of the residents have a care plan in which their assessed care needs are identified and the action required to meet them. The health care needs of the residents whose care plans were examined are being met. EVIDENCE: A sample of care plans was examined in the nursing wing to enable the inspector to familiarise herself with the methodology used as she had previously only inspected the residential wing. The sample inspected was found to be up to date and complete. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 11 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): None of these outcomes were inspected on this occasion. EVIDENCE: Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 12 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): None of these outcomes were addressed on this occasion. EVIDENCE: Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 13 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): 19,21,26. Overall the cleanliness and maintenance of the building are in good order. The laundry service is of a high standard and appreciated by the residents and relatives spoken to. The flooring in one of the toilets and the laundry are in need of repair/replacement. Appropriate hand washing facilities are not provided in the laundry. EVIDENCE: The inspectors toured the building and overall found all areas to be clean and well maintained. The standard of cleanliness is of a high level in all areas that the residents have access to. Two residents’ rooms did have an unpleasant odour and the housekeeper was addressing this at the time of the inspection. The inspector noted that the flooring in one of the toilets adjacent to the day room on the ground floor of the nursing wing, was pealing away from the wall and the floor. This makes the cleaning of the floor difficult and could in the Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 14 inspector’s view present a risk of cross infection to the residents. It is a requirement that the flooring in the toilet adjacent to the day room in the nursing wing must be made good. The laundry was visited by both inspectors and given the volume of work generated by the nursing and residential wing, the laundry assistants are to be commended on the service provided. The flooring in the laundry had previously had a coating that had worn off and was now showing the concrete base. This is not a suitable finish to be readily cleanable. The carpet in the clean room of the laundry is very worn and in some places torn which in the inspectors’ view could be a trip hazard to the staff. It is recommended that the flooring in the laundry should be recoated with an impermeable substance to ensure ease of cleaning, and the carpet in the clean room should be replaced. There are two steps into the laundry and the top step is chipped and broken, and in the inspectors’ view a risk to the health and safety of the staff who use the area. The laundry assistant when asked did say that she had tripped on a number of occasions, and that she had never reported this. It is a requirement that the broken step in the laundry must be made good. The inspector saw all communal areas of the home and several private rooms. Radiators were covered in some communal areas, but the inspector understood that none of the radiators and pipes in private rooms were protected. The inspector saw several rooms where the position of hot pipes and radiators could cause risk to residents, and understood from the registered manager that risk assessments have not been carried out to minimise the risk to residents. One bathroom has no heating and the bathrooms seen by the inspectors appear institutional and clinical. It is recommended that risk assessments should be carried out for all areas where radiators are not covered, including the dining room, and action should be taken to minimise the risk to residents, including the covering of pipes and radiators where necessary. Heating should be provided in the identified bathroom. Bathrooms should be refurbished to make them comfortable and homely. The laundry service is well managed, and clothing is usually labelled when new residents arrive. A sink is provided in the laundry, but in practice is rarely used for hand washing. Access is difficult and hand-drying facilities were absent on the day of inspection. The home’s health and safety policy says that hand washing facilities are provided, but on the day of inspection the facilities in the laundry were not fit for purpose. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 15 The inspector recommends, to improve infection control, that the sink in the laundry be thoroughly cleaned, be kept clear of obstruction and that appropriate hand cleaning and drying products be made available at all times. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 16 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. There are sufficient numbers and skill mix of staff on duty at all times. The recruitment policy and practices are in good order. The training and development opportunities for all staff are excellent. EVIDENCE: The inspector saw the staffing rota in the residential wing for the month, showing that the staffing over 24 hours is managed by four shifts. Recently a new shift has been introduced covering the evening period, and this has resulted in improved staffing levels. The nursing wing staff rota was examined and showed that a high level of agency and bank staff had been used. The registered manager explained that this was as a result of three staff who have recently left the home’s employ. Recent recruitment has been positive and once Criminal Records Bureau clearance, and references have been received, the new staff will be in post The home’s recruitment procedure was examined by the inspector and the sample of staff files was found to be in good order. The home is in the process of reviewing its policy in relation to recruitment at the present time and the draft was shown to the inspector. The manager on the residential wing is working to improve the numbers of staff with NVQ qualifications. At present 14 members of staff, including the Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 17 registered manager have either NVQ Level 2, 3 or 4, making 35 of care staff trained. 3 more care staff are undertaking the NVQ Level 2 training at present. One member of staff is undertaking the NVQ assessor training and when complete will be able to improve the rate at which the NVQ training is progressed at the home. Staff in the nursing wing are also working hard toward achieving NVQ qualifications. 10 staff have achieved level 2 and a further 9 are registered on the programme making a total of 35 of care staff in the nursing wing being trained. The registered manager stated how disappointing it is when you train staff and then they leave to find work and further training in the local hospitals. There is an excellent training plan that shows all the training provided for individual staff. The trained nurses are able to access the local training provision for trained nurses working in the care home sector. The inspector noted that a number of nurses were booked to attend training over the next few months. This programme provides an excellent opportunity for nurses to maintain their ongoing training to meet the registration requirements. The induction and foundation training has recently been improved by using a structured programme, including the assessing of competencies at the end of the process. Each member of care staff has a personal training file, and the inspector saw one individual’s file, showing that during the past year the individual had attended several appropriate training sessions. An audit of the staff training and supervision has been carried out and the action plan that came as a result of this has been completed. This is commendable. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 18 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): 31,32,33,35,38. Both of the registered managers are skilled, competent, and respected by the staff and residents. Every effort is made to ensure that the home is run in the best interests of the residents. There are good systems in place to safeguard the residents’ financial interest. Overall the health, safety and welfare of the residents and staff are promoted and protected. There are issues with the laundry environment, and an area of flooring in one of the toilets that require attention. Radiators and hot pipes are not covered in areas used by the residents. Fire safety lectures for staff are only provided once a year rather than twice a year as recommended by the fire service. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 19 EVIDENCE: The registered manager in the nursing wing is an experienced nurse manager who completed the NVQ Managers award in 2004. The registered manager in the residential wing is experienced and skilled, and also gained the Registered Managers Award in 2004. She recently completed the NVQ Level 4 qualification. She has also completed several distance-learning modules and is a trainer for Moving and Handling in the home. Several residents said that the managers are both approachable, good listeners, and offer good support to them. Staff were observed to be working very much as a team and there are clear lines of accountability that are understood by all. The quality assurance system has several strands, including residents and staff meetings, quality assurance questionnaires for residents and regular audits on different topics such as catering. Residents’ review meetings are also seen as an opportunity for quality feedback. The managers both operate an ‘open door’ policy, so that residents and relatives know that they can discuss any areas of concern as they arise. A quarterly “newsletter” is produced and this allows for feedback to be given on the results of any audits undertaken. Approximately 50 of residents control their own finances, and relatives or appropriate care managers take over when individuals can no longer manage. Small amounts of petty cash are managed for some individuals and the inspector saw that these are well managed and records are appropriately kept. The inspector saw the home’s health and safety document about safe working practices, which is given to all employees. There is a member of staff trained in first aid on duty on all shifts. Staff are also expected to keep updated with training as necessary. As discussed in Standard 25.5 Environment risk assessments have not been carried out regarding accidents to residents from hot radiators. Fire safety checks on equipment are carried out regularly, and the staff have instruction in fire safety, moving and handling and food handling. The inspector noted that the fire safety lectures have been given once a year. It is recommended that in consultation with the fire service that lectures in fire safety should be provided twice a year for each member of staff. Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 20 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 2 3 3 3 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 2 Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 21 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 OP26 Regulation 13(4)(c) Requirement Timescale for action 27/03/06 2 OP26 23(2)(b) It is a requirement that the flooring in the toilet adjacent to the day room in the nursing wing must be made good. It is a requirement that the 27/03/06 broken step in the laundry must be made good. 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 OP25 Good Practice Recommendations It is recommended that risk assessments should be carried out for all areas where radiators are not covered, including the dining room, and action should be taken to minimise the risk to residents, including the covering of pipes and radiators where necessary. Heating should be provided in the identified bathroom. Bathrooms should be refurbished to make them more comfortable and homely. It is recommended that the flooring in the laundry should DS0000027144.V270979.R01.S.doc Version 5.1 Page 22 2. OP26 Cherwood House Care Centre be recoated with an impermeable substance to ensure ease of cleaning, and the worn carpet in the clean room should be replaced. The washbasin in the laundry should be thoroughly cleaned and hand-washing liquid and towels should be supplied. It is recommended that in consultation with the fire service that lectures in fire safety should be provided twice a year for each member of staff. 3 OP38 Cherwood House Care Centre DS0000027144.V270979.R01.S.doc Version 5.1 Page 23 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.V270979.R01.S.doc Version 5.1 Page 24 - 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. 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