We carried out a review of the data available to us about Cherry Trees on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Cherry Trees, you can give feedback on this service.
Cherry Trees is registered to provide nursing, accommodation and personal care for up to 81 people, including people living with dementia. At the time of our inspection visit there were 67 people living at the home. Care is provided across two floors. Nursing care was provided on the ground floor in a unit called, ‘Young at Heart’. On the first floor, there was a separate unit for nine people with residential/dementia care needs called Cherry Blossom. This was not in use at the time of our visit; however, plans were being made for a potential opening in September 2021. The remainder of the first floor was called Memory Lane for people living with dementia. Communal lounge and dining areas were located on both floors. People’s bedrooms were ensuite and there were further communal bathroom facilities located on each floor.
People's experience of using this service and what we found
Since our last inspection, people, relatives and staff told us improvements at the home had been made. People and relatives said the overall experiences of living at Cherry Trees, was better. Staff said improvements had been made, especially in the management of the service.
People and relatives were complimentary about the service they or their relative received. Relatives told us, management, communication and feeling more involved in their family members care had improved and the quality of care.
People were safe because staff were recruited safely. People said they were safe because staff made regular checks on them or if they had a change in health, support was provided. Staff and the provider knew how to keep people safe and protected from abusive practice. Systems to learn lessons when things went wrong helped to drive improvements and the registered manager notified us and the relevant body at the right times.
People said staff were kind, caring, gentle and always willing to do what was needed and expected of them. People were cared for by staff who attended training relevant to their roles. Assessments were completed before care was provided. This helped to ensure staff had the relevant skills and knowledge to meet a person’s needs. Some staff said recent admissions and a lack of information upon admission, though not their fault, did cause additional pressures on the staff team before they got to know the person.
Staff followed infection control procedures in line with national guidance for reducing the spread of COVID-19. Regular cleaning took place; however, we found some communal dining rooms would benefit from further cleaning and checks to ensure standards were maintained.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People’s plans of care were detailed helping staff to provide safe care. Staff’s knowledge of how to support people was consistent with people’s care records and what people told us. Staff said there was limited or no reliance on agency staff, which meant the staff team worked well together because their knew people and their preferred routines.
Risks related to people’s care were recorded and reviewed. There were instructions for staff to follow to manage those identified risks. however, some risk assessments, such as those relating to specialist equipment, required more detail to be fully personalised. The registered manager assured us this would be addressed, conversations with staff showed they knew how to manage risk. In some examples, intervention by a GP or occupational therapist had been sought to help keep people safe.
Regular audits and quality checks were completed with oversight through internal compliance checks. People and staff were complimentary of the management team. Relatives we spoke with confirmed the quality of care was much better than when we last inspected in 2019. Relatives said the management team was approachable and responsive.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 29 October 2019) and there was a breach of regulation 12 safe care and treatment and regulation 17 good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
The inspection was prompted in part to follow up on action we told the provider to take at the last inspection. The inspection was also prompted in part by reviewing statutory notifications we had recently received from the provider where we had information related to two separate incidents of choking. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Cherry Trees is a purpose-built building registered to provide nursing, accommodation and personal care for up to 81 people, including people living with dementia. At the time of our inspection visit there were 67 people living at the home. Care is provided across two floors. Nursing care was provided on the ground floor in a unit called, ‘Young at Heart’. On the first floor, there was a separate unit for nine people with residential/dementia care needs called Cherry Blossom. The remainder of the first floor was called Memory Lane for people living with dementia. Communal lounge and dining areas were located on both floors. People’s bedrooms were ensuite and there were further communal bathroom facilities located on each floor.
People’s experience of using this service and what we found
Since the last inspection visit, we had received concerning information that indicated people did not always receive personalised care, specifically around staffing levels, falls management and risks related to people at risk of malnutrition and dehydration. The registered manager had left the service in July 2019 and the provider made sure, the service continued to be managed on a daily basis. During July 2019, the provider introduced and shared us with a management plan to drive improvements so we could be assured, people received good care.
During our visits, people and relatives told us they had concerns about staffing, in particular high agency staff usage which meant some staff did not always know people’s individual routines and preferences. Permanent staff said agency staff helped support planned staffing levels, however, they felt time was spent showing those staff what to do which did impact on the timeliness people received support. Several care and nursing staff had recently left so the staff team was supported by high numbers of agency staff. Plans were in place to recruit staff to those permanent roles.
Risks associated with some people’s care were not managed safely. For people with identified risks of malnutrition and or hydration, they were not consistently supported and records were not good enough to show, what levels of support people had received. Some people experienced weight loss but there was limited information to support what measures were being taken to respond to this because records of what people had consumed, were incomplete. People, relatives, staff comments and dining room record books told us some meals and choices were not always available to everyone or some food items were missing or not to the standard people expected.
Environmental risks in some cases continued to happen even though daily walkarounds gave assurances the risks were identified and managed. Safe food hygiene practice was not always followed by staff.
Mental capacity assessments, staff’s knowledge and how some people’s freedoms could be restricted, was applied inconsistently. There was variable information to show if the person had given consent, specifically when a relative’s decision was followed with no best interest’s decision recorded. Staff’s knowledge of deprivation of liberty safeguards was not always consistent and in line with best practice, so some people’s freedom of movement within the home, was restricted.
Medicines were administered safely however when some medicines where given covertly (disguised in food or drink), there was no information from a prescribing GP or pharmacist to show safe ways for this to be given. We saw plans to provide some epilepsy medicines on an as and when basis, were not consistent with care plan information and in one example, out of date pain relief continued to be given. The manager assured us actions would be taken to improve this.
People were complimentary of some staff, and relatives recognised staff did the best they could to support their family member’s needs. However, they shared some concerns with us that were similar to those at previous inspections. Relatives said at times it was difficult to find staff, especially at the busiest times of the days and when their concerns were raised, limited, or no action, was taken.
Relatives meetings had been held by the new manager in July 2019 to explain to people recent managerial changes and plans to provide a service people expected. Relatives told us they expected more from the provider in terms of stability of management, staffing and the levels of care provided. Some relatives said they had been in this position before, but some remained hopeful.
Staff were complimentary of the new manager and said they had started to feel supported and felt more comfortable to share any concerns they had. Although the management team was new to the home, confidence was becoming established.
The manager said care plans were being reviewed and whilst it was acknowledged this was a work in progress, there were inconsistencies in the level of detail in some care plans.
Some people were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the polices and systems in the service did not always support this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Good (published 8 November 2018).
During this inspection visit, we found similar themes we identified at the last inspection, however, some people’s care outcomes were not of a good standard. The service is now rated requires improvement and there was a breach of Regulation 12 of the Health and Social Care Act 2014 (Regulated activities) and Regulation 17 of the Health and Social Care Act 2014 (Regulated activities). Further improvement and embedding of the new management structure and their quality assurance oversight is required to ensure positive changes are incorporated into daily practice to improve people’s experiences.
Why we inspected
The inspection was prompted in part due to concerns received about staffing levels, high agency staff usage, people losing weight and people not always receiving their food and fluids in line with specialist advice. A decision was made for us to inspect and examine those risks.
We found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.
Follow up
We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Cherry Trees is a nursing home, which provides care for up to 81 people in three units, located across two floors. At the time of our inspection there were 68 people living at Cherry Trees. The nursing unit was on the ground floor called ‘Young at Heart’ and residential and respite care was provided on the first floor in ‘Cherry Blossom.’ People living with dementia were also supported on the first floor referred to as ‘Memory Lane’. People had their own bedroom and all the bedrooms had en-suite facilities, plus people had the use of shared communal lounges, a dining room and bathrooms.
People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
A requirement of the service’s registration is that they have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and the associated Regulations about how the service is run. At the time of our inspection visit there was a registered manager in post.
At our last comprehensive inspection in September 2017, we rated the service ‘Requires Improvement’ overall. We found the provider was in breach of two regulations of the Health and Social Care Act 2008 because insufficient staffing levels had a negative impact in how people received person centred care.
At this inspection we found improvements had been made and the overall rating had changed to ‘Good’. The provider had increased staffing levels at the home and people’s care and support needs were met, but better deployment of staff was needed at times, especially when shifts remained below the provider’s own assessed levels of staffing. We found the provider was no longer in breach of the regulations. However, the challenges of the environment meant some relatives shared continued concerns that staff were not always visible and ‘on hand’ to offer assistance to their family member when needed. The registered manager said they would consider how they communicated with relatives to assure them there were sufficient numbers of staff on duty to meet needs.
Staff protected people from risks of abuse. All staff understood what actions they needed to take if they had any concerns for people's wellbeing or safety. Staff felt confident to raise concerns with the senior staff, the registered manager and provider.
Staff received refresher training to continue to keep their skills, knowledge and practice updated. People’s care and support was provided by a caring and more consistent staff team, because the provider’s reliance on agency staff had reduced since the last inspection. Staff said reducing agency staff had improved communication and improved care delivery.
Staff worked within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff recognised the importance of seeking people’s permission before care was provided. Where people’s liberties were restricted, necessary approvals had been requested.
Staff were caring in their approach and interactions with people. The investment in keeping the environment safe and risk free showed the provider had considered how their actions impacted on those in their care.
The provider’s research and evaluation into their own dementia programme was to enhance the wellbeing of people living with dementia, especially those people living in ‘Memory Lane’. The provider’s research showed how this had improved people’s care across all their homes, such as reducing the number of falls, limiting the use of certain medicines and improving people’s wellbeing. This programme had been rolled out to all of their homes and the provider was in the process of accrediting each home over the next two years. Cherry Trees was not yet accredited. On Memory Lane, corridors were themed in colour and interests to help stimulate memories and conversations. However, staff’s knowledge needed to be embedded in day to day practice to best utilise the benefits of the provider’s dementia programme which looked at key themes and approaches.
There was stimulation for people to be involved in leisure interests to keep them active and to have fulfilling lives. People and staff were working together to help promote social and lifestyle skills.
Staff supported people to ensure they maintained a balanced diet and people had choice of what they wanted to eat and drink, with available drinks and snacks throughout the day for people to enjoy as they wished.
Staff knew people well and care plans suited the care and treatment people required. Nurse and care staff had good knowledge of the people they supported. A regular review of care plans was completed, but this needed to be improved. Some care plan information and risk assessment information did not reflect the person’s current situation and some plans would benefit from additional information to ensure consistent care continued.
People received support from other healthcare professionals to ensure their overall mental health and physical wellbeing was met. Regular checks and monitoring ensured medicines were given safely by trained and competent staff. Time critical and patch medicines were given safely in line with their prescription. Some inconsistencies were found in PRN (as and when medicines) protocols although we were satisfied staff knew when to offer these medicines safely.
Health and safety checks through daily walk around ensured the home remained suitable and safe for use. Examples of audits and checks were completed but further improvements to audits and checks when delegated to others, needed improving. Some checks had been completed with limited understanding of what was correct and there remained limited records to show what actions had been taken. The registered manager told us they and their team hard worked hard to drive improvements following the last inspection. The staff team wanted people’s experiences to be positive and what they deserved. The registered manager gave us a commitment that actions would be taken following our visit to continually improve the service and outcomes for people and their families.
Further information is in the detailed findings below.
Cherry Trees is a nursing home which provides accommodation and personal care to older people living with dementia, young adults and people with physical disabilities. Cherry Trees is registered to provide care for up to 81 people. At the time of our inspection visit there were 61people living at the home. The home provides nursing care across two floors. On the ground floor were people with physical disabilities and people living with dementia. On the first floor, referred to as ‘Memory Lane’, staff supported people living with dementia.
There was no registered manager in post. The registered manager left the service in April 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had ensured the home was supported by an ‘interim’ manager from within the organisation in the absence of a registered manager. The new manager who is referred to throughout this report as the “manager” had been in post since July 2017. The manager was in the processing of registering with us.
Cherry Trees was last inspected in April 2016 and was rated as ‘Good’. Prior to this inspection we received information that staffing levels did not always meet people’s needs. At this inspection, we found staffing levels impacted on the quality of care and service people received.
Staffing levels were unsafe because there were not enough of them to support people in line with their preferred choices and assessed needs. Some staff told us they enjoyed working at the home, however low staff numbers affected their morale because the service they provided was not to the standard they wanted. Before our second inspection visit, we received written confirmation from a senior regional director that staffing levels were increased by one staff member to support people living on ‘Memory Lane’. When we returned on 8 September 2017, staff said this had already made a positive difference and they were able to monitor people more responsively and not rush.
People living at Cherry Trees told us they felt safe. Care staff understood their responsibilities in being observant at all times to keep people safe. However, there were periods of time when communal lounges and areas of the home were not occupied because staff needed to support people elsewhere in the home. This placed some people at increased risk of not receiving support and assistance when required. We found information related to risks associated with people’s care was not always clearly recorded or consistently managed.
Staff knew how to recognise abuse or poor practice and told us they would report abuse if they observed this happening. We found that not all reportable incidents related to people’s health and safety had been reported to us.
Staff had been supported with training to help ensure they understood how people who lacked capacity could be supported to make decisions. Staff knew they could not undertake care practices against the wishes of people in the home. The management team had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People had been assessed to determine how decisions could be made in their best interests and applications for DoLS had been completed. Authorisations that had expired had been reapplied for.
People and our observations showed staff were mostly caring in their approach and people told us staff were kind and considerate. When staff were available in the communal areas, it was more reactive support rather than identifying situations were escalating so they could prevent things from happening. People had limited opportunities to pursue their hobbies and interests and staff had limited time to sit, talk, listen and involve them.
Staff knew about people’s wishes and preferences in relation to their care and worked to support people in accordance with their wishes. People were provided with a choice of food and drinks and people had their main meal at lunchtime. However, staff pressures meant some people did not always receive support with their meal when needed and some people were only given their lunch at 3.00pm, which was not their choice.
Nursing and care staff understood the importance of hydration and drinks were regularly provided throughout the day, however inconsistent records and relatives comments meant we were unsure this always took place. Where people had lost weight and there were concerns regarding their health, support from dieticians was sought.
People and relatives were not always positive in their comments of the management team and provider. Relatives who raised complaints with the provider told us they felt they were not always listened to and saw limited action taken to improve the delivery of service.
The home has experienced periods of managerial instability, such as changes to the registered manager and senior management. We found speaking with the senior management team, most of whom were new to this home, they were unable to account for what may have caused these issues. The senior management team were committed to driving improvements so people received a good standard of care, delivered by a staff team who felt valued and supported.
We found there were two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
You can see what action we told the provider to take at the back of the full version of the report.
Cherry Trees is a nursing home which provides care to older people living with dementia, young adults and people with physical disabilities. Cherry Trees is registered to provide care for up to 81 people. At the time of our inspection there were 55 people living at the home. The home provides nursing and care support across two floors. On the ground floor were younger people with physical disabilities and older people. On the first floor, referred to as ‘Memory Lane’, staff supported people living with dementia.
There was no registered manager in post. The registered manager left the service in January 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home was being managed by a manager but had not yet submitted their application to become registered with us.
Staff knew how to keep people safe from the risk of abuse. People told us they felt safe living at Cherry Trees and relatives agreed their family members felt safe and protected from abuse or poor practice.
The provider assessed risks to people’s health and welfare and wrote care plans that minimised the identified risks. However, some care records and risk assessments required updating to make sure staff provided consistent support that met people’s needs.
There were enough staff on duty to meet people’s health needs. The manager had recently reviewed people’s needs and increased nursing support on both floors. The manager continued to reassess staffing levels to ensure people living at the home, continued to receive a responsive and effective service. The premises were regularly checked to ensure risks to people’s safety were minimised.
People’s medicines were managed, stored and administered safely in line with GP and pharmacist prescription instructions.
People were cared for by kind and compassionate staff, who knew their individual preferences for care and their likes and dislikes. Staff understood people’s needs and abilities and they received updated information at shift handovers to ensure the care they provided, supported people’s needs. Staff training had improved and staff felt they had the right skills and knowledge to support people safely and effectively.
Nursing staff and care staff supported and promoted people’s choice, but they had limited understanding of mental capacity and their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Records showed consideration had been made if a persons’ liberty may be deprived, as the provider had made applications to the local authority.
People were offered meals that were suitable for their individual dietary needs and met their preferences. People were supported to eat and drink according to their needs, which minimised risks of malnutrition. Staff ensured people obtained advice and support from other health professionals to maintain and improve their health, and when their health needs changed.
People and their representatives felt recent changes at the home were for the better and people received care from a more consistent staff team. People benefitted from this because staff knew people well and were responsive to their individual needs.
Care was planned to meet people’s individual needs and abilities and care plans were reviewed although some information required updating to ensure staff had the necessary information to support people as their needs changed. People were supported to pursue their interests and hobbies and live their lives how they wished, and staff supported people to remain as independent as possible.
The quality monitoring system included reviews of people’s care plans and checks on medicines management. Actions plans were followed to ensure identified actions were taken. Accidents, incidents and falls were investigated and actions taken to minimise the risks of a re-occurrence. Improvements were required in assessing risks to people and how staffing levels were determined to ensure safe levels of care were maintained to a standard that met people’s welfare.
Sixty two people who required personal or nursing care were living at Cherry Trees at the time of our visit. The home was divided into three sections. On the ground floor younger people with physical disabilities were located alongside a unit called 'young at heart' where older people lived. On the first floor of Cherry Trees we saw older people with dementia were cared for in a unit called 'memory lane'. During our inspection we spoke with people from all the units at Cherry Trees.
Some people were unable to communicate with us verbally. We spent time in the communal areas of the home observing people to see how they spent their time, and how staff interacted with them.
We spoke with 11 people who lived at Cherry Trees about their experiences of the service. We also spoke with eight relatives about their family member's experience. We observed the care that was given to people during our inspection. We looked at care records at the home.
We spoke with a range of staff including six members of staff who provided personal care or nursing care to people at Cherry Trees, housekeeping staff, kitchen staff, the deputy manager, the manager, and the regional operations director of the service.
We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?
Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff who supported them and from looking at records. If you want to see the evidence supporting our summary please read our full report.
Is the service safe?
Staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the steps to take if they were concerned that abuse had taken place.
Safeguarding procedures were robust. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs). No recent applications had been submitted to deprive anyone of their liberty. Relevant staff were trained to understand when an application should be made and how to submit one. The manager was aware of the latest guidance and information on DoLs.
Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistle-blowing and investigations. This reduced the risks to people and helped the service to improve.
We looked around the home during our inspection to check the home was clean. We looked at the procedures in place to protect people from the risk of infection. We found people were cared for in a clean, hygienic environment.
Is the service effective?
People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.
We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate.
People had access to a range of health care professionals, some of which visited the home.
It was clear from our observations and from speaking with staff they had a good understanding of people's care and support needs and that they knew them well.
Is the service caring?
We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.
People and relatives we spoke with were positive about the care provided by staff. One person who used the service told us, 'What a lovely peaceful home this is, I really do like living here. Staff treat me in a respectful and kind way, with dignity and they respect what I say and listen to what I'm saying."
Is the service responsive?
We saw people were able to access help and support from other health and social care professionals when necessary.
People were able to participate in a range of activities both in the home and in the local community.
People who used the service, their relatives and other professionals involved with the service completed satisfaction surveys. Where shortfalls or concerns were raised these were analysed and addressed.
We looked at how complaints had been dealt with by the service. We found that complaints were investigated and dealt with in a timely way.
Is the service well-led?
Following our previous inspection of the service in May 2014, we asked the provider to make a number of improvements. At this inspection we found that actions to improve the service had been taken.
The service had a quality assurance system in place to identify areas of improvement.
We found staff were appropriately supported and supervised. We found staff employed to work at the home had the necessary skills needed to support the people who lived there.
People's personal care records were up to date and complete.
Sixty eight people who required personal or nursing care were living there at the time of our visits. The home was divided into three sections. On the ground floor younger people with physical disabilities were located alongside a unit called 'young at heart' where older people lived. On the first floor of Cherry Trees we saw older people with dementia were cared for in a unit called 'memory lane'. During our inspection we spoke with people from all the units at Cherry Trees.
Some people were unable to communicate with us verbally. We spent time in the communal areas of the home observing people to see how they spent their time, and how staff interacted with them.
We spoke with 11 people who lived at Cherry Trees about their experiences of the service. We also spoke with six relatives about their family member's experience. We observed the care that was given to people during our inspection. We looked at care records at the home.
We spoke with a range of staff including seven members of staff who provided personal care or nursing care to people at Cherry Trees, the deputy manager, the acting manager, and the regional operations director of the service.
The registered manager shown at the top of this report had left their role at the time of our visit. The acting manager has been in place for six weeks and was in the process of becoming the registered manager of the service. We refer to the acting manager in this report as the manager.
During our inspection we looked to see whether we could answer five key questions: Is the service safe, effective, caring, responsive and well led? Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
Staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the steps to take if they were concerned that abuse had taken place.
We found staff could raise issues of concern with the service. They were told about the whistle-blowing policy and procedures when they started working at the home. The whistle-blowing procedure ensured staff were protected during any subsequent investigation.
Safeguarding procedures were robust. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs). No recent applications had been submitted to deprive anyone of their liberty. Relevant staff were trained to understand when an application should be made and how to submit one. The manager was aware of the latest guidance and information on DOLs and was planning a review of their procedures to ascertain whether any changes were required to the policy.
Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistle-blowing and investigations. This reduced the risks to people and helped the service to improve.
We checked whether people's medicines were being managed safely. We found people's medication was being appropriately administered and safely managed.
We looked around the home during our inspection to check the home was clean. We looked at the procedures in place to protect people from the risk of infection. We found people were not always cared for in a clean, hygienic environment. We have asked the provider to send us an action plan stating how they will improve in this area.
Recruitment procedures were rigorous and thorough.
Is the service effective?
People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.
We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate.
People had access to a range of health care professionals, some of which visited the home.
It was clear from our observations and from speaking with staff they had a good understanding of people's care and support needs and that they knew them well.
Is the service caring?
We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.
People and relatives we spoke with were positive about the care provided by staff. One person who used the service told us, 'The staff are all lovely'.
Is the service responsive?
We saw people were able to access help and support from other health and social care professionals when necessary.
People were able to participate in a range of activities both in the home and in the local community.
People who used the service, their relatives and other professionals involved with the service completed satisfaction surveys. Where shortfalls or concerns were raised these were analysed and addressed.
We looked at how complaints had been dealt with at the service. We found that complaints were investigated and dealt with in a timely way.
Is the service well-led?
We reviewed the service at a previous inspection in September 2013, where we told the provider they must make a number of improvements. At this inspection we found that some actions remained outstanding. We were concerned that the service had not effectively monitored the completion of the action plan.
The service had a quality assurance system in place to identify areas of improvement.
We found staff were not always appropriately supported and supervised. We found staff employed to work at the home did not have all the necessary skills needed to support the people who lived there. We found staff were not offered regular yearly appraisals to monitor performance and identify training and development opportunities. We have asked the provider to send us an action plan stating how they will improve in this area.
People's personal care records were up to date and complete.
We looked at a number of areas following concerns from our previous inspection on 04 February 2013 to see whether any improvements had been made to the service.
We found overall there had been improvements made since our last inspection, but further improvement was required in some areas.
We saw that the care plans reflected people's individual needs and were comprehensive in detailing what support a person required. We found that some care plans were not always person centred as they did not contain information on how the person liked to be supported. We saw the members of staff supported people as detailed within their care plans and understood individual people's needs. We observed that staff were compassionate and caring when supporting people.
We found the personal call alarms that people used to request assistance did not always work correctly, if they were away from their bedrooms. This meant staff would be unable to locate the person promptly if they required urgent attention.
We found that within the dementia unit there were concerns with accurate information and the recording of people's medication.
We spoke with staff, people using the service and their relatives. People told us that there was poor staff morale, staff felt unsupported and staffing levels were insufficient to meet people's needs. A comment made by one person we spoke with was, 'Staff seem very busy and when we need them they don't come straight away.' We were told that this had impacted on people's care and support.
We saw that systems to supervise and appraise staff performance had not taken place. The staff training log showed shortfalls in staff training and staff told us that specialist training such as supporting people with challenging behaviour was not available. We were told of a lack of staff induction and mentorship for new staff.
We reviewed people's care records and found that some records did not reflect all aspects of their care. We saw evidence of incomplete records. This could put the person or staff member at risk as all of their needs and support had not been identified. We observed that monitoring of the service had not been robust.
We looked at medicines management across the home and found that it was not safe in a number of areas. The majority of our concerns related to the Oversley Wood unit.
Cherry Trees provides care for young physically disabled people, people with dementia and the frail elderly. During this visit we were assisted by two 'experts by experience' to visit all three units. These are people who have personal experience of using services such as this one or who have cared for someone who uses this type of care service.
We found improvements across all areas but found continued concerns in relation to involving people in their care/respecting people's choices and with staffing arrangements.
Many people at Cherry Trees had health conditions which restricted their ability to communicate or make choices about their care. We therefore relied on observation and discussions with visitors to obtain views about the service. It was not clear that people with limited communication were being involved in their care as much as they should. The expert by experience who observed the young physically disabled people told us: 'A number of people did not communicate verbally and staff did not appear to know how some people communicated saying that they did not communicate'. We saw that records did not clearly indicate communication methods.
Social activities were being provided and additional staff had made available to enable people to better access to these. Some people indicated that they were not aware the activities were taking place. One person in the young physically disabled unit said there were 'bad days' referring to lack of social activities provided for them.
People felt that their care needs were being met and this had been helped by the addition of a new general manager working in the home. They told us: 'I think X has been wonderful' (new general manager). One person told us about their care plan they stated: 'they have just reviewed it. I like to go for a walk'.it is in my care plan'. Others explained to us how staff supported them with personal care and told us staff were 'fine'.
We found that actions had been taken to ensure people were better protected from any potential abuse. Staff told us: 'Since X started as manager there have been much improvements, she works in a professional way and sorts out problems'. The expert by experience who witnessed a potential challenging behaviour incident between two people in the dementia unit, they told us: 'The carer quickly defused the situation by suggesting the lady went with her and I continued to talk to the man'.
Whilst we received positive comments about staff themselves it was evident that at certain times of day staffing arrangements were not effective. People told us: 'The staff are very good'. 'There are sometimes no staff in the lounges for what seems to be quite long periods of time'. We saw that some people were not experiencing a positive mealtime experience. Some people were still eating lunch close to 3pm.
Since our last visit improvements had been made on monitoring the quality of care and services. Audits of care records had been carried out to make sure they accurately reflected people's needs. Meetings had taken place with people and relatives across the three units. Areas for improvement had been discussed and action plans were in the process of being devised and implemented.
We found that people in the Frail Elderly (FE) and Young Physically Disabled (YPD) units were being given choices about their care provision in some areas but not others. Some of their preferences and choices regarding their care were evidenced through signatures of agreement in their care files. People in the YPD unit told us that their choices of social activities were limited. They told us that people who were dependant on staff to provide social activities would be 'bored'. Comments included :'I have never played 'Bingo' and would rather play 'Bridge' but I haven't been asked what I would like to do'. Relative meeting notes seen indicated that they felt some of the care plans for their relative were not representative of their needs and choices.
We saw that people in the dementia unit had regular access to social activities within the home. An outside entertainer was providing music entertainment in the dementia lounge on the day of our visit.
Some people spoken to told us they were happy with their care and that staff were kind but commented 'we need more staff' and told us staff appeared 'rushed' sometimes although they were 'willing and able' and respectful when providing care.
Relative meeting notes seen included the comments: 'The staff are second to none, helpful and so caring'. 'Impressed by the unit manager and his team'. 'Staff very tired and working lots of extra shifts to cover home. Staff very busy and some residents are being assisted to get up very late in the morning'. 'Too few pairs of hands'. 'Laughter has gone'. 'Some staff seem to lack motivation at times due to workload, relatives concerned for staff and residents'. Other comments in the notes included: 'Food reported to be generally good'. 'Injuries/falls/ incidents are reported to relatives promptly now'.
People on the ground floor told us about having to wait for long periods of up to 'half an hour' for staff to respond to call bells because the system was not compatible with the new environment.
We received both positive and negative comments from people on the dementia care and elderly frail units. People on the elderly frail unit stated: 'I am disappointed because I understood the dementia patients would be upstairs'. 'There are some quite nice people but some don't talk'.
Some people felt that the home was 'short staffed' and this had resulted in them not receiving the quality of care they would expect. People told us: 'On two mornings I wanted a shower and they didn't have time, its not cheap to be here', 'My nails were long and I asked for them to be cut. It took two to three days before staff could file them down'. 'I am happy enough'. 'The care is good without a doubt, one morning there was a hiccup with staff but normally fine'. 'X receives very good personal care and is always nice and clean'. 'I had a fall in the ensuite and called the bell but it didn't sound as an emergency so staff ignored it. I had to wait for about 15 minutes and had to get half up on my own'. 'Anytime up to 10.30am its difficult to get staff and I try not to ring the bell during lunch'. 'Staff are always caught up with someone else, if carers here go to hospital with someone it leaves them short'.
Due to the dependency needs of people on the younger physically disabled unit we decided to use an observational tool called 'Short Observational Framework for Inspection (SOFI). Observations undertaken in the small lounge identified negative outcomes for people. Staff appeared rushed and task orientated which resulted in minimal staff interaction with service users. Information was being provided to people at too fast a pace for them to understand and those attempting to seek attention from staff were ignored.
People told us that they were able to access a doctor when they needed one and some confirmed they had seen a dentist, chiropodist or hospital specialist. Comments included: 'The doctor comes quickly' when requested and 'The chiropodist lives locally and visits me regularly'.
We asked people what they thought of the food, some people said they enjoyed the food and a relative who was assisting a person said that the food was 'really good'. People told us: 'The food is not bad but presentation is a problem but they have to do food for a lot of people'. 'We didn't have lunch yesterday until 1.45pm'. 'The food is awful, lots of people don't go in' (to the dining room). They explained this was due to some people's eating habits.
People told us that they did not always feel their concerns were listened to and addressed. Comments included: 'The attitude of X puts me off raising concerns'. 'We raised with X but then we raised issues with XX because XX seemed more professional. XX seemed more sympathetic and comes back to you'.
People told us 'The home is always clean'. 'Sometimes the rooms are not hovered'. 'My room is cleaned regularly'. 'Sometimes the tray (food) is dirty'. 'I am very impressed with my room. The TV was not working and the next day it was sorted out'. 'The room is very pleasant but my mattress is hard and not comfortable, the sheets and pillow cases never seem fresh'. A relative confirmed that staff had said that the family could do 'anything they wanted to make it homely'.
People were generally positive about the staff that cared for them. One person spoken with said that the attitude of the staff was the reason the home was chosen as staff were 'Thoughtful, kind and compassionate'. Other comments included: 'Staff are mainly wonderful, there are a couple I find difficult'. 'Staff are very nice but always so busy, they have a really hard time'. 'The carers are not too bad'. 'Staff very welcoming'. 'Carers are alright'. 'Staff are quite pleasant, been very good'.
We were told there was a high number of staff from overseas, who despite being 'very kind, I couldn't understand them, as far as I am concerned their English is very poor'.