Cheriton Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of the legal regulations. Systems were in place to monitor the ongoing quality and safety of the service. However, these were not effective in ensuring issues from audits were actioned in a timely manner to mitigate risks to people. Records were not suitably maintained or audited to promote safe care and prompt reporting of reportable events to CQC and the Local Authority. The Duty of Candour regulation was not adhered to in that letters of apology following an incident were not sent to the person or their relative. The registered manager agreed to address those shortfalls in reporting. Plans were in place to promote more community involvement. Systems were in place to enable staff, people, and their relatives to provide feedback on care. People were aware who the registered manager was and felt they had a presence in the service. The registered manager was accessible and approachable to people and staff. Relatives confirmed that if ever they did have safety concerns, that they would be able to raise such issues with the registered manager and they felt that their concerns would be responded to. A relative commented “I have often spoken with [Registered manager’s name] at length, and I feel confident that they have their hands on things. I know that I can go to [Registered manager’s name] if I ever had an issue.”

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and staff told us they felt supported by the provider. Staff told us they felt there was good “teamwork” within the home. A staff member told us that the current management was better than previous managers the service have had. However, we observed staff were not providing high quality care or promoting the right culture, which is reflected in our finding of the safe and caring key question.

Team meetings took place to promote a shared direction and an open culture within the service. Other systems such as daily meetings and team WhatsApp messaging was used to promote communication across the team. However, the lack of effective oversight of the service meant high quality care was not provided or embedded in staff practice to promote the right culture to benefit people.

Staff told us they felt supported by the registered manager. One member of staff described the manager as “helpful and encouraging”. Staff were aware of the senior management team and appeared relaxed in their company. We reviewed whether the provider understood their responsibilities in respect of Duty of Candour. Duty of Candour is a legal duty to be open and transparent with people receiving care. We found incidents which had occurred had not been handled in line with legal requirements.

The registered manager had recently returned to the service after a period of planned absence. They were in the process of identifying and improving aspects of practice to improve care to people. They acknowledged some aspects around governance needed further embedding. Whilst the registered manager was compassionate, they were not responsive enough to ensure good quality care for all people to mitigate risks to them. These are identified under the safe key question.

Staff told us about the different methods they could use to speak up. Staff felt confident to raise concerns and told us they would be listened to by the registered manager and senior staff.

Systems were in place to enable people and staff to speak up. The service had a complaints procedure with the information on how to raise concerns or complaints displayed on notice boards. Resident meetings took place quarterly. The registered manager told us they operated an open-door policy and relatives were able to contact them by telephone or email if they had any queries or concerns. Systems were in place to annually obtain people, relative’s, staff, and professionals views. At the time of the assessment a survey was underway. Team meetings took place and staff were provided with one-to-one supervision meetings. This provided staff with opportunities to speak up. The provider had a whistle blowing policy in place to further promote speaking up.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were aware of their roles and responsibilities within the service. They were aware of the ways the provider and registered manager monitored the service. The provider’s quality and compliance audits at Cheriton Care Home had not been routinely carried out therefore some of the shortfalls we found had not been identified.

The providers quality assurance policy outlined the process for auditing and monitoring the service. Audits of practice were carried out which included infection control, health and safety, medicines, and care plans. However, audits had not identified the concerns we found in relation to risk assessments, the environment, staff interactions with people and recruitment practices. People’s records were not always accurate and contemporaneous. Other records relating to the running of the service, such as maintenance concerns did not always reflect when remedial action had been taken.

People had limited access to the community which they told us impacted on their well-being.

Staff told us they found staff meetings useful and felt the communication between them and the registered manager was good.

Partners had no specific feedback on this area.

The service worked in partnership with other professionals which included a private physiotherapist who visited the service weekly and provided both group or one to one therapy sessions. They liaised with the OWL guardian services, (Organisation that assists people with money management including benefit claims, power of attorney and appointeeship) local dentistry, opticians, and audiologists and used the Telemedical services on a regular basis to access medical advice for any medical emergency. The service have in the past taken part in garden parties organised by the local community and supported local businesses such as local farms. The registered manager confirmed a summer party was scheduled to take place in August 2024. They were sourcing activities lead by different organisations from the local community such as ball games, dancing and singing choirs. A choir had last visited the service in November 2023.

Staff told us they have access to regular training and were able to demonstrate some learning from this. However, a staff member told us some training did not always meet their learning needs. This was fed back to the registered manager to explore further with staff.

The service had a training matrix which indicated the majority of staff had the training required by the service. However, we saw some practices in relation to engagement with people, record keeping and failure to recognise potential safeguarding concerns demonstrated training was not embedded in practice. Whilst some improvements had been made since the previous inspection, we found continuous breaches of legal requirements, which meant improvements detailed in the providers action plan from the previous inspection had not been sustained. Innovative practices were not identified and promoted. The service failed to ensure people consistently got the care they required, that risks were mitigated, and that people had access to facilities to promote their care and well-being.