CQC report explained · a nursing home
What the CQC found at Cherry Blossom Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and that risks, staffing, equipment and infection control were managed safely. They made recommendations about disposing of unused medicines promptly and improving medicine care plans.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found clear management and governance systems, regular audits and a focus on learning and improvement. A small minority of staff reported low morale and poor working relationships, which the provider was addressing.
What inspectors found, November 2020
Cherry Blossom Manor was rated Good; inspectors found people safe and the home well-led, but medicine records and disposal needed improvement.
This was an unannounced focused inspection on 15 and 16 October 2020. Inspectors looked at concerns about risk management, medicines, staffing, infection control and how the home was managed. They spoke with people, relatives, staff and a visiting professional, and reviewed care, medicine, recruitment and management records.
People were protected from abuse and avoidable harm. Risks were assessed and managed, staffing was found to be enough to meet people's needs, and infection control measures were in place. Medicines were generally managed safely, but some out-of-date eye drops had not been removed and some medicine care plans lacked important information.
The home was rated Good overall, with Safe and Well-led both rated Good. This was a focused inspection, so the other key questions were not inspected and their previous ratings were used in the overall rating.
Protection from abuse
People told inspectors they felt safe. Staff understood safeguarding procedures and the provider had investigated recent concerns.
“People were safeguarded from the risk of abuse.” from the report
Risk management
The home assessed risks such as falls and pressure ulcers and set out the support people needed. Incidents were reviewed and actions were taken.
“The provider ensured potential risks to people's safety were identified, assessed and measures put in place to manage them.” from the report
Safe staffing
Although some staff said shifts were not always covered when someone was off sick, inspectors found enough suitable staff to meet people's needs safely.
“We found no evidence people were not receiving their care as required or that their safety was compromised.” from the report
Infection control
Inspectors were assured that the home used personal protective equipment safely, followed infection control measures and had arrangements for testing and outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Clear oversight
The home had management structures, audits and monitoring of risks. The provider used this information to identify trends and make improvements.
“There was a clear organisational structure and management at all levels of the home, both internally and externally.” from the report
Unused eye drops not removed
needs fixingEye drops for three people had been open for more than 28 days but were still stored with medicines in use. Inspectors recommended that unused medicines be disposed of promptly.
“However, for three people eye drops which had been open for more than 28 days were stored in the medicine trolley, alongside the eye drops currently in use.” from the report
Medicine care plans lacked detail
needs fixingSome care plans did not include important information about time-critical Parkinson's medicines, anticoagulant side effects or people's current medicines. Inspectors recommended reviewing the plans against best practice guidance.
“Medicine care plans were not always person-centred. Some people were prescribed medicines for Parkinson's disease.” from the report
Different staff experiences
minorMost staff described a positive culture, but a small minority reported low morale and poor working relationships. The provider knew about this and had introduced staff surgeries to hear concerns.
“A small minority of staff said, morale was low and they did not experience positive working relationships.” from the report
- 01What action have you taken to ensure unused eye drops and other medicines are removed and disposed of on time?
- 02How do you record time-critical Parkinson's medicines in each person's care plan?
- 03How do you record and explain the side effects and management of anticoagulant medicines?
- 04What has changed since the inspection to improve morale and working relationships in the community where concerns were identified?
- 05How do you make sure staffing absences do not result in care being rushed or delayed?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 24 November 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.
What inspectors found, March 2019
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced inspection on 19 and 22 February 2019. Inspectors spoke with people living in the home, relatives, staff and healthcare professionals. They observed care and reviewed care plans, medicines records, staffing information, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, trained staff and respectful relationships. People's care reflected their needs and preferences.
The rating had improved from Requires Improvement at the inspection on 5 April 2018. The earlier problems with staffing at busy times, support for people living with dementia, activities and management were reported as improved. No concerns were identified at this inspection.
Improved staffing
Staffing had improved since the previous inspection. Inspectors saw enough staff to support people during lunch, including people who needed help to eat.
“We observed people eating lunch. Staff were attentive to people's needs and meal times were calm and unrushed.” from the report
Kind and respectful care
Staff knew people well and provided patient, compassionate and individualised support. People's dignity, privacy, choices and independence were respected.
“We observed that staff were compassionate, patient and kind. They knew people well, took time to speak with people and provided individualised support.” from the report
Support for individual needs
Care planning covered areas such as communication, mobility, nutrition, faith and social values. People living with dementia received better support at important times.
“This meant the provider was no longer in breach of this regulation.” from the report
Strong quality oversight
The home used development plans, audits, incident reviews and staff handovers to monitor and improve care. A registered manager was in place, unlike at the previous inspection.
“Effective systems were in place to assess and improve quality and safety in the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How do you make sure there are enough staff during meals and other busy times?
- 02How do you provide individual support for people living with dementia, particularly when they need help eating?
- 03What activities are available for people who do not enjoy larger group activities?
- 04How are a person's end of life wishes, pain relief and preferred place of care recorded and followed?
- 05What changes have been made to medicines management through the work with the clinical commissioning group?
This was an unannounced inspection of the overall service, covering all five CQC questions and both the care provided and the care home premises. This explanation was written from the published report of 15 March 2019 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 Blossom Manor
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- November 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 26 April 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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