Cherry Tree Lodge Nursing Home

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 Good. At this assessment the rating has changed to 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 service was in breach of legal regulation in relation to safe care and treatment.

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 service did not consistently demonstrate a culture of learning and improvement. Incidents were not always investigated thoroughly, and learning was not consistently shared or embedded across the team. Opportunities to learn and improve were missed and there was limited evidence of proactive risk management. For example, 1 person experienced multiple falls, however incident forms were reviewed at the end of the month rather than immediately after each incident. This delay meant opportunities to identify learning and implement preventative measures were missed. The service was not fully open or transparent following incidents, which meant lessons were not always identified or acted upon to prevent recurrence. Altercations between people using the service were not consistently reported to external agencies and no rationale was recorded for why this did not happen. CQC were not always notified of incidents as required.

Systems were in place for hospital admissions and staff were able to print hospital care plans. However, care plans did not always include all the necessary information to support safe and effective care. The service was relying on a hybrid approach of using both paper and electronic records, although not all professionals we spoke with were aware of this. Professionals told us communication was sometimes inconsistent, which meant there was a risk important information could be missed. Despite this, the service had policies and guidance in place for making referrals and ensuring safe transition between services. Pre-assessment paperwork was completed in full before people moved into the service. Staff told us they felt communication was effective when new people moved in and when people’s needs changed following hospital admissions. Professionals told us when a person had moved into the service at short notice, staff did as much as possible to ensure the environment was appropriate and welcoming, which helped the person feel safe and comfortable.

Safeguarding procedures were not always followed. Relatives told us they felt comfortable raising concerns with the registered manager. However, when concerns were raised, for example when a person had unexplained injuries, these were not investigated or reported to the local safeguarding team or notified to CQC as required. This meant people were at risk because safeguarding concerns were not escalated appropriately. Although there was a process to record concerns, investigations were not consistently carried out. Training records showed not all staff had completed training in Safeguarding or the Mental Capacity Act 2005. The provider told us the training statistics may have been affected by new starters or staff due for renewal. However, 1 staff member told us they believed their safeguarding training may be out of date which did not assure us staff had the required training. While applications for Deprivation of Liberty Safeguards (DoLS) were made, the service had not always ensured relevant person representatives (RPR) were involved. This meant an authorisation was only granted short term so it could be reviewed again. Despite these concerns, people told us they felt safe, and observations confirmed staff treated people with kindness and respect. Staff understood their responsibilities in relation to safeguarding and knew who to inform and told us they felt comfortable raising concerns.

Risks relating to people were not assessed and managed appropriately which meant people were at risk of unsafe support. For example, a person was having regular falls, some of which resulted in hospital admissions with injuries. Although the risk assessment showed the person was high risk of falls, information was lacking around how staff should manage risk and information in care plans was not detailed enough for staff to consistently keep people safe.

Care plans did not clearly show how staff should attempt to de-escalate situations when people's behaviour was communicating a need, emotion or distress. Language used in some care plans was negative and did not promote dignity. For example, 1 care plan described a person as 'aggressive' and stated they attacked others but included no information about cues and triggers to help staff better understand the person. It was not always clear how some staff supported people when they became distressed. For example, 1 staff member told us, “I can handle [person], they have hit out and push and punch, we can deal with them.” This language did not demonstrate a person-centred approach, and suggested staff may rely on reactive rather than proactive strategies to keep people safe. A strategy used in some people’s care plans stated staff were to give them 'time out', which is an outdated and restrictive practice. Daily notes showed staff sometimes removed people to their rooms, which could negatively impact their wellbeing and limit their freedom of choice.

Arrangements were in place to monitor the safety and upkeep of the premises, including bringing in qualified people to complete the necessary safety checks. The safety of the premises including communal and personal spaces were checked and managed to support people to stay safe. However, some areas of the premises required maintenance, and certain aspects of the environment did not consistently present a welcoming or visually appealing appearance.

Fire safety arrangements were not robust and did not provide assurance that people could be evacuated safely. A recent fire risk assessment stated evacuation plans were unachievable within a safe timeframe. There were insufficient fire drills to ensure staff knew how to keep people safe in an emergency. Some staff told us they had received online and practical training and felt confident with the fire procedures, but this was not supported by regular drills to test staff knowledge and response in practice.

There were not enough staff to ensure people consistently received safe, good quality care that met their needs. Observations and records showed people did very little during the day to provide stimulation, and staffing levels meant staff mostly only met people’s basic needs. When people received one-to-one support, there was no evidence this was used effectively, or at all, to ensure people received the support they required to achieve a good quality of life.

Most staff told us they felt more staff were needed, particularly at certain times of the day, and now some people required more support with eating and drinking. A staff member told us, "Sometimes it's frustrating for [people] they have to wait when feeding 1 person to finish before they can go to them next. Some [people] can even have a seizure because of this trigger." Another member of staff told us, "Extra staff would be a blessing."

Training statistics showed not all staff had completed the provider’s mandatory training. This meant there was a risk staff did not always have up-to-date knowledge required to keep people safe. Training that was not mandatory but specific to people’s conditions, for example Down syndrome awareness and epilepsy, was not consistently enforced, and training statistics showed completion rates were low.

Despite these concerns, staff received support through inductions and regular supervision. There were robust and safe recruitment practices in place to make sure all staff were suitable fortheir role. People experienced continuity of care as they were supported by a regular staff team.

Systems were in place to reduce the risk of infection, however some areas required improvement to ensure these measures were fully effective. There were some areas in the environment, such as unpainted surfaces and floors that were not sealed properly, which could harbour germs and bacteria as they could not be cleaned thoroughly. This meant there was a risk infection prevention measures were not always fully effective.

Despite this, there was an effective approach to assessing and managing the risk of infection, which was in line with current national guidance. People were protected as much as possible from the risk of infection because premises and equipment were clean and hygienic. Staff understood the importance of food safety, including hygiene, when preparing or handling food, and followed required standards and practice. Staff were aware of when they needed to wear personal protective equipment (PPE) and knew how to dispose of it properly. Training records showed staff had completed training in infection prevention and control.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Systems for managing medicines were not always effective. A controlled drug stock discrepancy had not been recorded or reported, and previous checks failed to identify the error. When investigated during the inspection, staff were unable to determine how or when it occurred, indicating checks were incomplete. Processes were in place to report medicines incidents, but none had been documented since 2024. The controlled drug discrepancy should have been reported. Meeting minutes showed missed signatures on the electronic MAR, which were not recorded as incidents.

Protocols for ‘as required’ (PRN) medicines were in place but were not always person-centred. For example, guidance for people who could not communicate verbally lacked detail on recognising pain. Pain assessment tools were available but not used consistently.

Care plans did not always provide clear guidance on supporting people with medicines. For example, a care plan for a person with epilepsy did not explain how staff should respond during a seizure beyond administering prescribed medicine.

Bowel charts were not completed daily for people who needed them, and staff only recorded when a bowel movement occurred. This created a risk that medicines for constipation might not be given when needed.

Although we identified concerns regarding the accuracy and completeness of medicine recording, staff demonstrated kindness and compassion when administering medicines to people.