Report evidence summary
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Unavailability of a registered care home manager
Wider context from the report “6. The home is currently without a registered manager and has been for sometime .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to offer analgesia to residents reporting pain after a fall
Wider context from the report “4. Mr. Harris was not offered any analgesia despite his reports of pain .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to ensure carers read residents’ care plans and risk assessments
Wider context from the report “1. At the time of his fall none of his carers ████████ had not read his care plan or risk assessments .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to accompany residents assessed as at risk of falls when mobilising
Wider context from the report “2. His care plan stipulated that he was at medium risk of falls and should be accompanied when mobilising yet he mobilised to the bathroom from the lounge without assistance because the only member of staff present in the lounge was assigned to a resident requiring one to one observation and therefore could not accompany Mr. Harris .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to record routine resident checks
Wider context from the report “5. Records of routine checks on residents are not made . Therefore whilst it was asserted that Mr. Harris was checked hourly throughout following the fall there is no evidence that the checks were carried out, by whom and what was found .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to make the falls protocol clearly available to staff
Wider context from the report “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████
████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017 ,
although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to sufficiently educate and assess staff on falls policy awareness and application
Wider context from the report “All of the above contribute to a concern that staff at Cherry Lodge are not being sufficiently educated at falls policy and assessed on their awareness and application of policies , and also that there is inadequate record keeping.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to follow the falls protocol requiring immobilisation and medical attention after a painful fall
Wider context from the report “3. Having fallen Mr. Harris complained of pain in his groin. The home’s ‘Protocol for all Falls’ included that if the resident complains of pain in any part of the body following a fall they ought not to be moved and medical attention should be sought. Medical attention was not sought and Mr. Harris was returned to his room. The three carers who gave evidence at the inquest ████████
████████ and ████████ all gave evidence that they had not seen the document entitled ‘Protocol for all Falls’ prior to Mr. Harris’ fall on the 26th January 2017,
although ████████ and ████████ were not found to be credible witnesses, ████████ was credible. Evidence of police investigations identified that the Protocol ought to have been clearly available for staff around the home as a result of issues raised by the CQC prior to this incident.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor the provider’s application to register the new manager.
Verbatim wording from the response “The Registered Provider made attempts to recruit a Registered Manager and an offer was made to one applicant to start in June 2017 but they then later declined. At the inspection it was confirmed that a new manager had been in post at Cherry Lodge since 14 July 2017, and CQC were advised that they were in the process of applying for registration. CQC will monitor this application and the provider has been made aware that failure to have a registered manager places them in breach of their registration and could result in criminal enforcement action.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a comprehensive inspection of Cherry Lodge and complete the inspection process.
Verbatim wording from the response “Further, in light of the additional information above and as part of the CQC assessment of risk, a decision was made that the date of the next scheduled inspection of Cherry Lodge would be brought forward. A comprehensive inspection (‘the inspection’) took place on the 15, 17 and 22 August 2017. In line with the CQC’s inspection processes, the findings of this inspection will be published on the CQC website. The official rating of this inspection cannot be publicly reported on until the CQC have completed the entire inspection process. This includes the Registered Provider being given the opportunity to respond and challenge any factual inaccuracies they deem to be in the report.’” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the inspection findings on the CQC website.
Verbatim wording from the response “Further, in light of the additional information above and as part of the CQC assessment of risk, a decision was made that the date of the next scheduled inspection of Cherry Lodge would be brought forward. A comprehensive inspection (‘the inspection’) took place on the 15, 17 and 22 August 2017. In line with the CQC’s inspection processes, the findings of this inspection will be published on the CQC website. The official rating of this inspection cannot be publicly reported on until the CQC have completed the entire inspection process. This includes the Registered Provider being given the opportunity to respond and challenge any factual inaccuracies they deem to be in the report.’” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Bring forward the scheduled comprehensive inspection of Cherry Lodge.
Verbatim wording from the response “the CQC had received, we revisited our assessment process. As part of CQC’s assessment of risk the decision was made to wait for the outcome of the Coroner and police investigations’ before deciding if we needed to take civil or criminal action.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide new-resident needs information at each daily handover.
Verbatim wording from the response “1) Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor staff records and address issues arising from record completion.
Verbatim wording from the response “6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put care plans and risk assessments in place specifying supervision requirements during mobilisation.
Verbatim wording from the response “2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Record residents’ hourly or two-hourly nightly checks on signed night-check sheets.
Verbatim wording from the response “4) Records of nightly checks are in place. This identifies when residents were checked either hourly or two hourly at their request. This is then recorded on the night check sheet and signed by staff on duty.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include the falls policy in recorded staff supervision to clarify responsibilities after a resident fall.
Verbatim wording from the response “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the falls protocol to staff and incorporate it into new-staff induction.
Verbatim wording from the response “3) Protocol for falls – this document has been given to all staff and a signed copy is kept on their personnel file. This has also been made part of the induction protocol for new staff.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement read-and-sign care-plan sheets for staff caring for newly admitted residents.
Verbatim wording from the response “1) Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add the falls policy to staff-meeting agendas as a lessons-learned item.
Verbatim wording from the response “7) The falls policy now forms part of the Staff member’s supervision which is recorded. This is to clarify the member of staff understands their role and responsibility and what is expected when a service user has a fall. It will also be on the staff meeting agenda as a lessons learnt.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Speak individually with Cherry Lodge staff about accident and incident roles and responsibilities.
Verbatim wording from the response “6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a manager in post at Cherry Lodge.
Verbatim wording from the response “6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Register the Cherry Lodge manager with CQC.
Verbatim wording from the response “6) There is a manager in post at Cherry Lodge at present. ████████ does have registration for another service and will register with CQC in due course. Staff are being spoken to individually at Cherry Lodge as to their understanding and their roles and responsibilities in the event of any accident or incidents in the home. Management staff are monitoring records that staff are completing and addressing any issues arising from this.” Source location 2017-0334-Response-by-Care-First-Class-UK
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Decisions on civil or criminal action were deferred pending the outcomes of the police and Coroner’s investigations.
Verbatim wording from the response “the CQC had received, we revisited our assessment process. As part of CQC’s assessment of risk the decision was made to wait for the outcome of the Coroner and police investigations’ before deciding if we needed to take civil or criminal action.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No further action was considered necessary based on the information available in February 2017.
Verbatim wording from the response “In accordance with CQC processes, we considered the information we had available to us at that time (February 2017) to determine whether the service was meeting the The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“The Regulations”). Based on the information available to us at this time it was decided that no further action would be taken.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care staff cannot administer non-prescribed pain relief because the home is not a nursing home and staff lack necessary clinical skills.
Verbatim wording from the response “The Registered Provider had a system to ensure that service users received their prescribed medication, including medicines prescribed on an as required basis. However, individual care staff had not followed the provider’s protocol when Mr Harris complained of pain. The policy of the Cherry Lodge was not to offer or keep homely remedies on the premises. This means, if a service user required pain relief not already prescribed by a GP, a care worker cannot administer the medicine. In such an event, the Registered Provider’s protocol is to call for assistance either through 111 or 999. Cherry Lodge is not a nursing home and as such care staff do not have the necessary clinical skills to make judgments about people’s health, or the risk associated with administering medication that had not been prescribed.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Registered Provider remains responsible for employing sufficient suitably qualified staff to support service users safely.
Verbatim wording from the response “The Registered Provider is responsible for ensuring sufficient numbers of suitably qualified, competent, skilled and experienced care staff are employed in order to minimise and reduce the risk of harm to service users, (Regulation 18 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). If there is a lack of care staff there is a risk that service users will not receive the level of support required to keep them safe from risk of harm.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Registered Provider remains responsible for ensuring monitoring checks are conducted and accurately recorded.
Verbatim wording from the response “The Registered Provider has a duty to ensure processes are followed to protect service users from the risk of harm, which includes monitoring the checks made on service users were conducted and reviewing the records of these checks. The care staff at Cherry Lodge were aware that they should have recorded when checks were made on Mr Harris. However, the Registered Provider has the overall responsibility to ensure there are appropriate processes in place which should ensure regular monitoring checks are made on people and accurately recorded.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Registered Provider is responsible for ensuring staff competence, training, and compliance with care plans, risk assessments, policies and procedures.
Verbatim wording from the response “The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and the appropriate actions to take by following a service users care plan. If care staff fail to read care plans there is a risk that they will not provide the care that is appropriate to a specific service user and thus putting that service user’s safety at risk.” Source location 2017-0334-Response-by-Care-Quality-Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Residents may mobilise without waiting for assistance, creating risk despite care plans requiring supervision and staff assisting when they observe this.
Verbatim wording from the response “2) Care plans and risk assessments are in place. Care plans stipulate if a resident requires supervision on mobilising and staff do endeavour to be with residents when walking. Unfortunately, some residents will not always wait for staff to assist and therefore put themselves at risk. If staff observe a resident mobilising independently and are aware that they should be accompanied then they will always assist.” Source location 2017-0334-Response-by-Care-First-Class-UK
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