Cheriton Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance and informing us of events they are required to.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

We received mixed feedback on the culture of the service. A relative commented, that they sometimes see and sense a tension in the staff and a staff member indicated that on occasions staff are spoken down too in a less respectful way by other senior staff. This was fed back to the provider to observe and address.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

We received positive feedback from staff, people and relatives about the management of the service. However, we found the service was not always safely managed and people were placed at risk.

People and their relatives were complimentary of the registered manager. They felt they had brought about positive changes. Relatives commented, “I really rate [The registered manager’s name], she has done a good job in lifting standards,” and “Yes, I knew there was a new Manager there, we are very satisfied. Over the years we have been, and we still are, confident that any issues are dealt with and attended to.”

Staff described the registered manager as ‘approachable, supportive and had brought improvements to the service’. A staff member commented, “Overall I am pleased with the improvement in the atmosphere and the new Manager’s influence and effect in managing poor performance.”

A visiting professional commented, [The registered manager’s name] has made the greatest impact. There has been a huge improvement in the visual aspects of the home, creating a more homely feel. The cleanliness of communal areas has also improved. Their approach appears more structured and there seems to be better harmony, teamwork and effectiveness, all of which have a positive result on the care and well-being of the residents.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard.

The provider had systems in place to promote speaking up. These included a whistle blowing policy, team meetings and supervisions.

Staff were surveyed in April 2025. The results of the survey raised no concerns. Surveys were not taking place of people, relatives or stakeholders. The provider assured these were scheduled to commence during December 2025.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service had a diverse group of staff employed, with systems in place to support them with their religious and cultural needs. The provider accommodated flexible working for staff to enable them to meet their family commitments which enabled the provider to retain key staff members.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this with others when appropriate.

Whilst auditing had commenced and issues were being identified, auditing processes were not fully embedded in practice to promote effective monitoring to enable the provider to identify the shortfalls we found in the service.

People’s records and records relating to the service were not always accurate. Records were not accurately completed to indicate people were repositioned, checked, given personal care, or bathed/showered at the frequency required. As a result, there were gaps in people receiving personal care. The senior care records did not accurately reflect the care provided to people and the lack of auditing of those records resulted in people being exposed to risk and neglect.

In a person’s daily records, it was recorded that bed rails were in use which contradicted their risk assessment. During feedback with the provider, they confirmed the person did not have bed rails in place and this was a records issue that they agreed to address with staff.

The rota was not accurate to reflect the staff on duty. A staff member was recorded on the rota with 2 different names. The provider confirmed this was the same staff member. The rota showed they worked 12 nights in succession without a night off in between. The recording of them twice on the rota meant this was not identifiable and therefore not identified that they were working long shifts in succession. The training matrix provided did not accurately reflect all training that the provider told us had been completed and the fire training records were not always signed off by the registered manager to be assured of staff’s competencies in relation to being a fire marshall on shift.

The service is required to inform us without delay of serious injury incidents, allegations of abuse and any incidents reported to the police. In the providers accident and incident analysis report we saw incidents such as injuries requiring hospital treatment was not reported to us and not identified by the providers own analysis of the incidents. These were completed in retrospect.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked with other health professionals and the Local Authority. A visiting professional commented, “I enjoy my professional visits to Cheriton Care home, where I feel a valued member of the team, providing a service to the residents. Communication with all the staff is also good.”

At the time of the inspection people were not accessing the community. The provider confirmed they were keen to have more community involvement, and this was being developed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Whilst systems were in place and being developed to promote continuous learning, these were not yet fully embedded in practice. However, in response to our feedback the provider assured us they were committed to improving the service and sent us an action plan to outline how the concerns from our findings were to be addressed and monitored.