Cherry Tree Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safeguarding people from the risk of harm. The provider is now in breach of regulation 12 as medicines were not managed safely.

This service scored 50 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager recently implemented stronger methods for recording accidents and incidents. Previously, while necessary safety actions were taken, records were not systematically stored. This meant it was unclear at times what action had initially been taken. Accidents and incidents were now discussed during handovers and team meetings.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager and staff supported people and their families to identify safe transitions where people’s needs changed. Staff worked closely with health and social care partner agencies to ensure effective communication and people received timely care and treatment. Professionals spoke highly about how the service worked with them to ensure people were safe and received the care they needed.

The provider did not always work with people and healthcare partners to understand what being safe meant to them and the best way to achieve that.

During the assessment, we identified two incidents which should have been reported to the CQC. The information had already been shared with the local authority, and after the inspection, the registered manager submitted the required notifications to us.

People and relatives felt the service was safe and people were protected from abuse. A relative told us, “We are so happy with the home as the staff are wonderful.” Staff understood how to protect people from abuse. One staff member told us, “If I see something and I am worried, I want to make sure the residents are safe. If I am worried, I would report, I recognise the need to report my concerns.”

Some risk assessments were insufficiently detailed to ensure safety; however, both staff and the registered manager demonstrated comprehensive knowledge of appropriate support when interviewed. The registered manager acknowledged the need for more thorough written records. The registered manager was reviewing risk assessments as people’s needs changed, such as falls or changes in health conditions.

The environment was safe and met people’s needs. The provider had made improvements in how they detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care. There was a system to manage the maintenance of the building and premises. We reviewed evidence that demonstrated the provider had necessary checks and certificates. The provider had an ongoing programme of maintenance and improvement to ensure the building, fixtures and equipment continued to be kept in good working order.

People’s rooms were personalised to a very high standard and people were encouraged to bring their own belongings, so people felt comfortable. People and their families told us the home was spotless, and this was important to people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff on duty to meet the needs of people who used the service. Throughout our visit, we observed there were staff available to meet people's needs in a timely manner. We observed staff were not rushing and had the time to sit with people if they needed. There was enough staff to support people at meals time. Staff told us they felt there was appropriate staffing levels.

The provider carried out checks on the suitability of staff before they started working at the service. These included checks on their identity, eligibility to work in the United Kingdom, references from previous employers and Disclosure and Barring Service (DBS) checks.

Staff told us they had effective support and development opportunities and added they completed online training to maintain their knowledge.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. In people’s care plans there was information advising staff how to reduce the risk of the spread of infections. The provider had policies around infection prevention and control and staff spoke knowledgably about the importance of hand washing and the need to stop the spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicines were not always administered in accordance with prescribed instructions. For example, we saw one person was administered a medicine at the same time as other medicines, despite the label stating these items should not be given together.

Another person was administered time critical medicines at different intervals to the one prescribed, without any evidence the changes in timing had been agreed with the healthcare professional. Therefore, we could not be assured the medicines would have the desired therapeutic effectiveness.

When required medicines’ (PRN) protocols were in place for most prescribed medicines. However, there was no PRN protocol for one-person prescribed eye drops and another person prescribed laxative therefore we could not be assured that staff had all the information needed to support these people to administer their PRN medicines appropriately.