CQC report explained · a residential care home
What the CQC found at Cherry Garth
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found better risk assessments, incident reporting, safeguarding and staffing. However, a medicine was dropped and administered, one medicines fridge was outside the recommended temperature range, deep cleaning was needed, and agency workers sometimes arrived late.
- Effective?
- Requires improvement
- Care assessments, staff training and healthcare support had improved. Some care plans were overdue for review, fluid records had gaps, and staff appraisals and some supervision arrangements needed improvement.
- Caring?
- Good
- This question was not assessed during this inspection. The rating from the October 2019 inspection was used to calculate the overall rating.
- Responsive?
- Requires improvement
- Care plans were more personalised and activities were varied and well resourced. Some records lacked detail when people's health changed, and complaints made through head office were not always entered in the home's complaints register.
- Well-led?
- Requires improvement
- Management oversight, audits, communication and the improvement plan had improved. Further sustained improvement was needed in leadership, record keeping, carrying actions forward, staff morale and completing the duty of candour process.
What inspectors found, January 2023
Rated Requires Improvement; the home has improved from Inadequate and is no longer in special measures, but important shortfalls remain.
This was an unannounced focused inspection over four days. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, staff files and management records.
The home had made significant changes since the previous inspection. Risk assessments and care plans were rewritten, staffing had improved, incident reporting was better, and medicines safety had improved. The provider was no longer breaching regulations.
Inspectors still found areas needing attention. These included medicines procedures, some incomplete records, deep cleaning, vacancies and agency staff arriving late, complaints not always being logged locally, and workplace morale.
The overall rating is Requires Improvement. Safe, Effective, Responsive and Well-led were each rated Requires Improvement. Caring was not assessed during this inspection, so its older rating from 2019 was used in calculating the overall rating.
Improved care planning
Risk assessments and care plans had been rewritten and were more individualised. Staff knew people's needs and provided comfort and compassion.
“Care plans had improved and reflected a more person-centred approach.” from the report
Better staffing levels
Inspectors found enough staff were deployed to meet people's needs, although the home still had many permanent vacancies.
“There were enough staff deployed on shifts to meet people's needs.” from the report
Health support
The home worked with community health and social care professionals. People's health needs, oral health and access to healthcare were supported.
“People's health was assessed, maintained and promoted because the service worked well with community health and social care professionals.” from the report
Improved management oversight
Audits and an improvement plan were in place, and management had become more proactive in following up actions.
“There were improvements to systems and processes in place to ensure safe, compassionate, well-led care.” from the report
Medicines procedures
seriousStaff did not always follow the home's medicines policy. Inspectors saw a medicine dropped on the floor and then given to a person, and found inaccurate fridge temperature records.
“We saw staff drop a medicine on the floor and pick it up and administer it to the person.” from the report
Staff vacancies and agency cover
needs fixingThere were many permanent staff vacancies. Agency workers sometimes arrived late, temporarily leaving fewer staff than planned, although the home had steps to reduce the risk.
“There was a large number of staff vacancies for permanent roles. The service used agency workers to fill shifts.” from the report
Incomplete records
needs fixingSome incident actions were not completed or marked as complete. Some care notes did not fully describe changes when people became unwell.
“Actions to be taken were recorded in the computer system. They weren't always finished, followed up or marked as complete.” from the report
Infection control cleaning
needs fixingInspectors found that carpets and some furniture needed deep cleaning. The management team said this would be done promptly.
“Deep cleaning of carpets and some furniture was required.” from the report
Complaints recording
minorMost complaints were investigated and answered, but complaints sent directly to head office were not always recorded in the home's local register.
“The provider had not ensured that complaints raised directly at head office were logged into the service's register.” from the report
Staff morale and communication
needs fixingStaff morale had improved but some staff still felt unheard. Relatives also said that useful information was not always communicated to them.
“Staff morale had improved, however some staff still felt they were not always listened to or that their feedback was not always acted on.” from the report
- 01What has been done to make sure all staff follow the medicines policy, including safe handling of medicines dropped on the floor?
- 02How are you filling the permanent staff vacancies, and how do you check that agency workers know each person's needs?
- 03Has the deep cleaning of carpets and furniture been completed, and how is this checked?
- 04How will you make sure care notes fully record changes when someone becomes unwell?
- 05How are complaints received by head office now recorded and followed up at the home?
This was an unannounced focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and its October 2019 rating was carried forward to calculate the overall rating. This explanation was written from the published report of 21 January 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, March 2022
Rated Inadequate and placed in special measures; inspectors found serious risks involving medicines, staffing, safeguarding and management.
This was an unannounced focused inspection. Inspectors visited on 19 and 20 January 2022 and spoke with people, relatives, staff, managers and other professionals. They reviewed care records, medicines records, staff files and management documents. They also made telephone calls to relatives on 24 January.
The home was not safe. Medicines were not managed properly, risk assessments were often out of date or contradictory, and incidents were not thoroughly investigated. There were also problems with safeguarding, staffing levels and infection control. These issues put people at risk of avoidable harm.
The home was not well-led. Improvement work was too slow, records were inaccurate, required notifications were not always sent to the CQC promptly, and feedback was not used effectively. The overall rating changed from Requires Improvement, published in February 2020, to Inadequate.
The home was placed in special measures. The CQC said it will keep the home under review and normally re-inspect within six months to check for significant improvements.
Staff knew people
Inspectors found that care staff knew people and their needs well.
“Care staff knew people and their needs well.” from the report
Person-centred support
Care staff were observed to provide support in a polite and patient way.
“Support was provided to people in a person-centred way by the care staff.” from the report
Some capable managers
The home manager and deputy manager were described as knowledgeable and experienced, and worked well together.
“The home manager and deputy manager were knowledgeable, skilled and experienced.” from the report
Visiting updates
Relatives said they were generally told about changes to visiting arrangements.
“Relatives stated they were informed of any changes to visiting.” from the report
External partnership
The provider was working with the local authority, clinical commissioning group and other partners on improvements.
“The service was working closely with the local authority and clinical commissioning group to develop safe care practices for people.” from the report
Medicines were not safely managed
seriousThere were multiple medicines incidents, problems with storage temperatures and stock records, missing allergy information and medicines that had not been applied or given as prescribed.
“Systems were not effective to ensure the proper and safe management of medicines. This placed people at risk of harm.” from the report
Risks and incidents were not controlled
seriousRisk assessments were often out of date or contradictory. Incidents were sometimes reported late, were not properly investigated and were not used to prevent similar events happening again.
“Overall themes and trends from accidents and incidents were known, but not effectively analysed and acted on to prevent recurrence.” from the report
Safeguarding systems were inadequate
seriousAllegations were not always examined promptly, investigations were insufficient and some staff had not completed safeguarding training.
“People were not protected from abuse and improper treatment.” from the report
Staffing levels were sometimes too low
seriousSome shifts had unfilled posts and staffing fell below the home's own minimum level. Staff and relatives said this affected the care people received.
“Sufficient numbers of suitably qualified, competent, skilled and experienced staff were not deployed.” from the report
Infection control was unsatisfactory
seriousInspectors found missed screening checks, unsafe use of protective equipment and waste, and hygiene information that was out of date.
“Effective systems were not in place to prevent and control the spread of infections.” from the report
Improvement was too slow
seriousThe action plan had many overdue items, records remained inaccurate and feedback was not turned into planned improvements.
“The provider did not always effectively assess, monitor and improve the quality and safety of the service.” from the report
- 01What has changed in medicines storage, stock checking, allergy recording and the investigation of medicines incidents since the inspection?
- 02How are you now making sure every shift has enough staff, including weekends and other previously unfilled shifts?
- 03How are safeguarding allegations and incidents now investigated, recorded and reported without delay?
- 04Which overdue actions from the 50-item improvement plan have been completed, and what evidence can you show?
- 05How are care plans, risk assessments, food and fluid charts, and repositioning records now checked for accuracy?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 1 March 2022 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 Garth
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2022Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- October 2011
Registered with the Care Quality Commission on 31 October 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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