CQC report explained · a residential care home
What the CQC found at Cherry Tree Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm, with improved risk assessments, safeguarding processes, staffing and medicines systems. They noted that some skin patches were not always rotated in line with the manufacturer's instructions, and food in communal fridges was not always dated when opened.
- Effective?
- Good
- This area was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not inspected during this focused inspection. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- Care plans included people's preferences and communication needs. Inspectors saw enjoyable activities and found that activities and community events had improved, although the daily 'Tools Down' approach was not yet fully embedded.
- Well-led?
- Good
- A new management team had improved audits, care planning, staff training and oversight. Staff and relatives described better communication and felt able to raise concerns.
What inspectors found, April 2023
Rated Good; inspectors found safer, more organised care after improvements, with a few medicines, infection control and staff time issues still to watch.
This was an unannounced focused inspection on 13 April 2023. Inspectors spoke with people living at the home, relatives, staff and healthcare professionals. They reviewed care records, medicines records, training, recruitment and quality checks.
The home was rated Good overall for the areas inspected: Safe, Responsive and Well-led. Inspectors found enough staff on the inspection day, better risk assessments, safer safeguarding processes, accurate medicines records and more personalised activities and communication.
The home had improved since its previous Requires Improvement rating in December 2021. A new management team had strengthened audits, staff training and oversight. The provider was no longer in breach of regulations at this inspection.
This was not a full inspection of all five areas. Effective and Caring were not inspected, so their previous ratings were carried forward when calculating the overall rating.
Improved management
The new management team had strengthened audits and created a development plan to track improvements. Inspectors found that previous regulatory failures had been addressed.
“Action had been taken to ensure the provider's audit systems operated effectively, and areas for improvement within the service were identified and addressed.” from the report
Safeguarding and risk
Staff understood how to identify and report safeguarding concerns. Risks were assessed and care plans explained how staff should reduce them.
“Risks to people had been assessed, identified and reviewed. Risk management plans contained information on how staff should support people to mitigate identified risks.” from the report
Medicines
People had their prescribed medicines, and records checked by inspectors matched the medicines held on the trolleys.
“Accurate medicines records were maintained. We carried out checks of boxed medicines held on the medicine trollies.” from the report
Activities and communication
Care plans recorded people's preferences and communication needs. Inspectors saw people enjoying singing and baking, and relatives said activities had improved.
“Staff supported people to engage in group activities they enjoyed. We saw people taking part in planned group activities during our inspection visit.” from the report
Open leadership
Staff said managers were visible and listened to concerns and suggestions. Relatives described improved communication and positive changes in the home.
“Staff felt able to raise concerns and share suggestions, confident they would be listened to.” from the report
Skin patch recording
needs fixingStaff recorded where skin patches were applied, but not always in line with the manufacturer's instructions. The deputy manager said this would be addressed immediately because correct rotation reduces the risk of skin sensitivity.
“Staff recorded the site of application on a body map, but these were not always in line with the manufacturer's instructions.” from the report
Food dating
minorFood in communal fridges did not always have its opening date recorded. The manager had already identified this and was addressing it with staff.
“However, we identified food in communal fridges had not had the date of opening recorded on it as required.” from the report
Protected staff time
needs fixingThe home had a daily approach asking staff to spend time with residents, but this was not yet consistently part of staff practice.
“Although this was an agreed approach, the registered manager acknowledged this was not yet fully embedded within staff practice.” from the report
Staff sometimes busy
needs fixingAlthough inspectors found enough staff on the day, some people said staff could be busy and occasionally had to leave while helping them.
“Sometimes they are in the middle of helping you and they dash off to help somewhere else.” from the report
- 01How do you now check that skin patches are applied and rotated according to the manufacturer's instructions?
- 02How do you make sure all food in communal fridges is dated when it is opened?
- 03How consistently is the daily 'Tools Down' time being used for staff to spend time with residents?
- 04How do you respond when residents feel staff are too busy to stay and finish helping them?
- 05Which ratings for Effective and Caring were carried forward from the previous inspection?
This was a focused inspection of Safe, Responsive and Well-led, while the previous ratings for Effective and Caring were carried forward. This explanation was written from the published report of 28 April 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, December 2021
Inspected but not rated; inspectors found serious concerns about safe care, safeguarding and management, while the previous rating remained Requires Improvement.
This was an unannounced targeted inspection on 15 November 2021. Inspectors looked mainly at risk management, safeguarding, accident and incident records, and infection prevention and control. They spoke with staff and managers and reviewed care records and service records.
Inspectors found that people did not always receive safe care. Risks were not always identified or managed quickly, some safeguarding concerns were not referred properly, and records of accidents and incidents were incomplete. Staff did not always receive enough information about changing risks.
The home had some infection control arrangements in place, but inspectors found problems with mask use, staff testing and cleaning records. The provider was required to produce an action plan with tight timescales and managerial oversight. CQC said it would monitor progress and return for another inspection.
The service was inspected but not rated because this was a targeted inspection, not a full review. The previous overall rating was Requires Improvement from 13 September 2019, and that rating remained in place.
Some infection controls were in place
Inspectors were assured about several areas, including visits, admissions, shielding and social distancing, and preventing or managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
An improvement plan was produced
The provider acknowledged the shortfalls and sent CQC a detailed action plan with timescales and management oversight.
“Their detailed action plan with tight timescales and managerial oversight would ensure action was taken to improve standards and practice at the home.” from the report
Risks were not managed reliably
seriousCare plans and observations did not always reflect people's risks. Inspectors found delays in putting plans in place and poor recording of observations.
“People did not consistently receive safe care. Risks associated with people's care were not always identified, managed or mitigated.” from the report
Safeguarding responses were inconsistent
seriousSome potential abuse concerns were not referred to the right external agencies promptly. Staff also said they did not always receive feedback after reporting concerns.
“We found an inconsistent approach by managers and senior staff to the management of incidents that were safeguarding concerns.” from the report
Incident records were incomplete
seriousSome accidents and incidents were not recorded in enough detail or included in the monthly analysis. This limited the provider's ability to identify patterns and learn lessons.
“Accidents or incidents were not always recorded, or recorded in enough detail, to ensure actions were taken to keep people safe.” from the report
Management systems were not robust
seriousChecks did not consistently identify risks or ensure that care plans were updated. Senior staff needed more training and support, and staff lacked confidence to challenge poor practice.
“The provider did not have robust enough systems in place to ensure action was taken in response to risk.” from the report
Infection control needed improvement
needs fixingSome people did not wear masks in line with guidance. Staff testing did not follow government guidance, and some shared-area cleaning records were not kept up to date.
“We were somewhat assured that the provider was using PPE effectively and safely.” from the report
- 01Which actions from the inspection plan have now been completed, and what evidence can you show that they are working?
- 02How do you make sure every safeguarding concern is referred to the correct external agency and reported to CQC when required?
- 03How are people's risk plans and observation records checked and updated when their needs or behaviour change?
- 04How do managers review all accidents and incidents, including incidents involving more than one person, and make sure lessons are acted on?
- 05How do you check that staff follow current mask, testing, cleaning and infectious-waste procedures?
This was a targeted inspection of specific concerns about risk management, safeguarding records and reporting, governance, and infection control; it did not assess the full five key questions or change the previous rating. This explanation was written from the published report of 15 December 2021 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 Tree Lodge
7 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2021Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2019Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- March 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Goodstayed GoodWell-led: Requires improvement
- January 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- December 2012
Registered with the Care Quality Commission on 10 December 2012.
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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