CQC report explained · a residential care home
What the CQC found at Cherry Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Rated Requires Improvement; the home has improved from Inadequate and left special measures, but care planning and quality checks still need fixing.
Inspectors carried out an unannounced comprehensive inspection on 4 and 5 December 2023. They spoke with people, relatives and staff, observed care, and checked care, medicines, staffing and management records.
The home had improved since its last inspection. People were safer, medicines were generally given correctly, staffing and recruitment had improved, and staff treated people with kindness. Consent arrangements, emergency records and infection control had also improved.
However, some care plans and risk assessments were not detailed or up to date. People did not always receive activities that matched their interests. Care reviews were inconsistent, and the systems used to monitor quality and learn from incidents were not reliable enough.
All five areas were rated Requires Improvement. The home was no longer Inadequate or in special measures, but the provider remains in breach of rules about person-centred care and good governance.
Improved safety
People received medicines safely and as prescribed. Manual handling, food preparation and storage of sharps had improved since the previous inspection.
“At this inspection we found people received their medicines safely and as prescribed.” from the report
Enough permanent staff
Inspectors saw enough staff on duty, and recruitment checks had been completed. The provider had reduced its reliance on agency workers.
“Our observations during the day indicated there were enough staff on duty to support people with their care needs.” from the report
Kind and respectful care
Inspectors observed kind interactions. Staff described ways of protecting people's dignity during personal care.
“We observed kind and caring interactions between staff and people.” from the report
Better consent practice
People could leave and return to the home, CCTV consultations had taken place, and mental capacity and best-interest decisions were recorded when needed.
“At this inspection we found people had access to key codes and could leave and return to the home as they wished.” from the report
Positive staff support
Staff said they felt valued and able to raise concerns. They received training, supervision and opportunities to discuss improvements.
“Staff told us they felt valued, and their views were respected.” from the report
Care plans and reviews
seriousSome people and relatives were not involved in care reviews. Some reviews were late, and agreed actions, including requests for activities, were not recorded as completed.
“Some care plan reviews were not completed within the timescales set out in people's care plans.” from the report
Weak quality monitoring
seriousManagement checks did not always identify missing or outdated information. The provider did not consistently show that it was monitoring quality and safety effectively.
“Systems were not robust enough to demonstrate effective monitoring of the quality and safety of the service.” from the report
Learning from falls
needs fixingIncident records were completed, but the home did not always identify patterns or put preventative measures in place after falls.
“Further work was required to ensure patterns and trends are identified and strategies put in place to reduce the likelihood of reoccurrence.” from the report
Meaningful activities
needs fixingSome people spent most of the day in one communal area and were not always offered activities linked to their interests and hobbies.
“Some people had not always been supported to access activities of interest or receive care based on their preferences.” from the report
Outdated medicine instructions
needs fixingSome covert medicine records were out of date and did not clearly explain how the medicine should be added to food or drink.
“Some people's covert medication protocol records were out of date.” from the report
- 01How will you make sure every person's care review happens on time and includes the person and their relatives where appropriate?
- 02What activities are planned for my relative's interests and hobbies, and how will you check they are offered and taken up?
- 03How do you investigate falls and make sure preventative actions, such as checking alarms or increasing observations, are completed?
- 04How are outdated care plans and covert medication instructions found and corrected?
- 05What actions are included in the monthly improvement reports sent to CQC, and what progress has been made so far?
This was an unannounced comprehensive inspection covering all five key questions and both the care provided and the premises. This explanation was written from the published report of 27 January 2024 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 2023
Cherry Lodge was rated Inadequate and placed in special measures; inspectors found serious concerns about safety, people’s rights, dignity and management.
This was an unannounced inspection. It began as a focused inspection after CQC reviewed concerns, but was widened to a comprehensive inspection covering all five key questions. Inspectors visited on 8, 9 and 15 November 2022, and completed inspection activity on 22 November 2022.
Inspectors found that risks were not always identified or managed. Records for care, medicines, nutrition, incidents, recruitment, staff training and fire safety were incomplete or unreliable. People were also subject to a blanket restriction on leaving the home, without proper consideration of their rights or individual risks.
Care was often task-based. People were not consistently involved in decisions, care planning or activities, and staff did not always communicate with compassion or protect privacy. The provider had breached regulations about safe care and treatment, consent, dignity and respect, person-centred care, good governance and staff recruitment.
The overall rating was Inadequate. Safe, caring, responsive and well-led were all rated Inadequate, while effective was rated Requires Improvement. The home was placed in special measures and CQC said it would monitor progress and normally re-inspect within six months if the provider’s registration was not cancelled.
Medicines competency
Staff leading medicines rounds had received medicines training and had their competence checked. Inspectors also found that daily medicines were administered safely.
“People were supported by staff who had received training around medicines management and who had had their competency checked to ensure medicines were given safely.” from the report
Visiting arrangements
Relatives said they could visit when they wished, with no restrictions in place at the time of the inspection.
“A relative told us, "I can attend whenever I want. [There are] no restrictions.” from the report
Some positive feedback
Some relatives described staff as friendly, helpful and attentive. Inspectors also saw that people were dressed comfortably and presented well.
“We saw people were dressed comfortably and well presented.” from the report
Risks were not managed
seriousInspectors found unsafe food preparation, poor monitoring of weight loss, an ineffective sensor mat, accessible hazards and gaps in cream records. These problems placed people at risk of avoidable harm.
“The provider had failed to ensure safe care and treatment was being provided to people.” from the report
People were unlawfully restricted
seriousEveryone was prevented from going out independently, including people whose records said they had capacity. There was no proper balancing of independence and safety for people who might need support.
“People were unlawfully restricted and there was a blanket restriction across the home, preventing all people from going out.” from the report
Dignity and privacy
seriousStaff did not always involve people in care or respond to their wellbeing. Medicines records were left accessible and some care discussions took place in corridors.
“People were not consistently supported to receive support in a caring and dignified manner and have their privacy respected.” from the report
Care was not personalised
seriousPeople and relatives were not routinely involved in care assessments or reviews. Care plans lacked important information about people’s needs, interests and preferences.
“People had not been involved in planning or reviewing their care or received care that was based on their preferences.” from the report
Weak management checks
seriousThe provider’s audits and monitoring did not identify or correct repeated problems. Incident and complaint information was not used effectively to improve care.
“Systems were not robust enough to demonstrate effective monitoring of the quality and safety of the service.” from the report
Recruitment checks
seriousSome staff files did not contain full employment histories or recruitment decisions. Two staff members had previous employers’ DBS checks, but the provider had not completed its own checks or risk assessments relating to recorded convictions.
“The provider had not ensured robust recruitment practices were in place.” from the report
- 01What has been done to identify and manage risks involving nutrition, food texture, falls, medicines and the environment?
- 02How are residents now supported to leave the home, and how are individual capacity and safety decisions recorded?
- 03How are residents and relatives involved in writing and reviewing care plans?
- 04What checks are now in place to ensure staff recruitment, DBS checks and risk assessments are complete?
- 05How will you show that audits, complaints and incidents lead to lasting improvements?
The inspection began as a focused follow-up but was widened to a comprehensive inspection covering all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 24 February 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.
Every inspection of Cherry Lodge
6 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2023InadequateSafe: InadequateEffective: Requires improvementCaring: InadequateResponsive: InadequateWell-led: Inadequate
- November 2020Inspected but not ratedSafe: Inspected but not rated
- April 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2014
Registered with the Care Quality Commission on 19 August 2014.
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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