CQC report explained · a nursing home
What the CQC found at Cherry Holt Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not consistently managed, including risks from water temperatures, pressure area care and fire evacuation plans. Medicines were not always managed safely, although the provider acted during the inspection.
- Effective?
- Requires improvement
- Some care assessments lacked detail and some health referrals were delayed. Training gaps and refurbishment issues were identified, but staff supported nutrition, consent and access to healthcare.
- Caring?
- Good
- People were treated with dignity and respect, and staff were observed to be patient and supportive. People's choices, preferences and involvement in care planning were respected.
- Responsive?
- Good
- People received personalised support and were helped to follow interests, maintain family relationships and access activities. Complaints were recorded, investigated and responded to in line with the home's policy.
- Well-led?
- Requires improvement
- Quality checks did not always identify problems or make sure they were fixed. The culture was described as open and person-centred, and the manager created an action plan after the inspection.
What inspectors found, September 2023
Requires Improvement; inspectors found kind and personalised care, but medicines, risk management and quality checks were not reliable enough.
Inspectors visited the home without advance notice on 3 and 4 July 2023. They spoke with people, relatives, staff and a healthcare professional. They observed care and checked care plans, medicine records, recruitment files, training records and management audits.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were also rated Requires Improvement. Caring and Responsive were rated Good.
Inspectors found risks were not always monitored properly. Some people may not have received prescribed medicines, and some referrals and care records were delayed or incomplete. The building was being refurbished and did not always meet people's needs.
There were positive findings too. People generally described staff as kind and respectful. The home supported activities, family contact, food and drink, choice and end of life care. The provider took significant action during the inspection and was asked to send an action plan.
Kind and respectful care
People and relatives said staff were kind and respectful. Inspectors observed patient and supportive interactions, apart from one isolated concern that was acted on.
“Staff supported people with kindness and compassion. We observed staff to be patient and supportive to people.” from the report
Personalised support
Staff understood people's likes, dislikes and individual needs. People were involved in planning their care and could choose who supported them.
“People were supported by staff who had a good understanding of each person's individual needs.” from the report
Activities and relationships
People were supported to take part in activities linked to their interests and to keep in touch with family members.
“People were supported to choose and engage in a range of activities.” from the report
Open management
The manager was described as approachable and supportive. People, relatives and staff were encouraged to give their views, and actions were taken after meetings.
“The culture was person centred, inclusive and open.” from the report
Good end of life support
End of life wishes were recorded and specialist advice was sought when needed. Training on end of life medicines had recently been completed by nursing staff.
“End of life wishes had been discussed and documented within care plans.” from the report
Medicine safety
seriousMedicine records had missing signatures, some prescribed medicines had run out, and creams were not always dated or stored securely. This meant people were at risk of harm.
“People were at risk of not receiving their prescribed medicines.” from the report
Risk checks
seriousSome risks were not properly monitored. Inspectors found scalding water, inconsistent repositioning records and unclear fire evacuation instructions.
“Risks were not consistently managed or monitored. This placed people at an increased risk of avoidable harm.” from the report
Incomplete care information
needs fixingSome care plans and assessments lacked detail, including one for a person with COPD. This could mean staff did not have the information needed to provide safe support.
“Some assessments lacked detail to ensure staff had the correct information to support people safely.” from the report
Delayed healthcare referrals
needs fixingSome referrals to health and social care professionals were not made promptly. Inspectors found delays involving speech and language therapy and specialist falls support.
“Referrals to some health and social care professionals were not always made in a timely manner.” from the report
Weak quality monitoring
seriousAudits identified some problems but did not always lead to lasting improvements. Medicine problems continued after an earlier audit had identified them, and an unsafe snooker table was not found by the environmental audit.
“Internal quality assurance processes were not always effective in monitoring the service.” from the report
Premises and communication information
minorThe home was being refurbished, signage needed improvement, and menus were not always available in suitable formats. The provider took action on some of these points.
“The premises and environment were under refurbishment therefore did not always meet the needs of people.” from the report
- 01What changes have been made to prevent prescribed medicines running out and to make sure every medicine administration is recorded?
- 02How do you now check pressure area care, water temperatures and fire evacuation arrangements?
- 03Have all care plans been reviewed following the move from paper records to the electronic system?
- 04How quickly are referrals now made to speech and language therapy, falls services and other health professionals?
- 05What evidence can you show that the action plan has fixed the problems found by the inspection?
This unannounced inspection looked at the care home, nursing care and premises across all five CQC questions, including infection prevention and control; the report was prompted partly by concerns about nursing care, infection control and medicines. This explanation was written from the published report of 2 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2020
Rated Outstanding; inspectors found exceptionally caring, effective and responsive support, with safety rated Good.
This was an unannounced planned re-inspection on 28 January 2020. One inspector spoke with people, relatives, staff and outside professionals. They observed care and checked care plans, risk assessments, medicines records, training and quality checks.
The home was rated Outstanding overall. Effective, caring, responsive and well-led were Outstanding. Safe was Good. Inspectors found kind and patient staff, strong care planning, safe medicines, good staffing levels and a clean, well-maintained environment.
Inspectors particularly praised the home’s personalised activities, end of life care, food and nutrition support, staff training and community links. Records were accurate and people and relatives were involved in decisions about care.
The previous rating was Good, published in December 2016. The report says the four Outstanding ratings improved from Good. An inspection in June 2019 was withdrawn because there was an issue with some information gathered.
Kind and personal care
Staff were described as affectionate, patient and highly attentive to people’s individual preferences. Inspectors saw a welcoming and inclusive home where people were treated as individuals.
“People and their relatives experienced affection and patience at all times and were enabled to feel at home in an extremely welcoming, vibrant and inclusive environment.” from the report
End of life support
The home planned ahead with people and families and worked closely with specialist professionals. People’s wishes were recorded and respected.
“End of life care was exceptional. The service was acknowledged as a leader in developing and using best practice.” from the report
Activities and relationships
Activities were varied and included outings, group events and one-to-one time. Staff made efforts to support people’s interests and relationships.
“The variety of activities was outstanding.” from the report
Staff knowledge and training
Staff received additional training linked to people’s health needs. Inspectors found that this helped staff provide timely and effective care.
“Care staff received training above and beyond their core role to ensure people were supported by knowledgeable staff informed by best practice.” from the report
Strong leadership
The management team had clear systems for checking care and records. Staff and outside professionals said leaders supported improvement and shared good practice.
“The registered manager led the service exceptionally well.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you keep medicines audits and stock checks accurate, and how are staff competencies assessed?
- 02How would you support my relative to continue their hobbies, relationships and outings, including if they were unable to leave their room?
- 03How would you involve my relative and our family in advance care planning and end of life decisions?
- 04What additional training would staff receive for my relative’s specific health needs?
- 05How can we raise a concern, and how will you keep us informed about the response?
This was an unannounced planned re-inspection covering all five CQC questions, with the previous June 2019 report withdrawn because of an issue with some information gathered. This explanation was written from the published report of 22 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cherry Holt Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingdown from OutstandingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2020Outstandingup from GoodSafe: GoodEffective: OutstandingCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 20 May 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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