Cherry Tree Lodge Nursing 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 Good. At this assessment the rating has changed to 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 governance at the service.

This service scored 54 (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 have a written vision or strategy to guide its approach to care. Staff were not aware of any formal values or objectives that shaped the service’s culture. This meant there was no clear framework to ensure decisions and care delivery were aligned with principles such as transparency, equity, equality and inclusion.

Despite this, staff spoke positively about the registered manager and described feeling supported in their roles. While this was encouraging, the absence of a documented vision and strategy limited assurance that the service was consistently working towards shared goals.

The registered manager had the skills, experience, and capability to lead effectively, and staff spoke positively about the support they received. A staff member told us, "[The] manager's office is open and she's always walking around. She does a lot with the residents which is nice as not a lot of managers do this." Another staff member said, "She is very caring. She shows a lot of empathy to staff and residents. Communicates well. Encourages to show their potential. She listens when you contribute."

However, the registered manager did not always have sufficient time to carry out their leadership responsibilities because they were frequently required to provide direct support due to staffing levels. This meant that while staff felt supported, the registered manager did not always have enough time to carry out their role effectively. As a result, oversight and the development of the service were limited and progress was slow.

There were systems in place to support staff to raise concerns. For example, a whistleblowing line displayed in the service, a 24-hour telephone line to head office and contact details for the regional management team. Staff told us they could speak to the registered manager and described them as approachable. The regional manager told us they visited the service when the registered manager was not there so staff could talk to them directly. One staff member told us, “I feel comfortable. If I have something to say, I will.”

Leaders took some steps to promote equality, diversity and inclusion, but this was limited to what was practical rather than a clear commitment. Cultural awareness training was needed to improve staff understanding and reduce misinterpretation. Staff highlighted areas for improvement, “I have noticed a lack of awareness of different cultures, lack of knowledge in terms of awareness. Certain people from certain areas may look rude or sound rude. There is a need for training of culture awareness.” This showed gaps in cultural understanding could lead to misinterpretation and negative perceptions.

Responses had been made to accommodate people’s religious needs, such as ensuring a staff member had a room to pray in. This was positive as it demonstrated flexibility and respect for individual beliefs, helping staff feel valued and included.

Systems were in place to monitor quality, but not always effective in driving improvements or improving outcomes. For example, regional manager audits showed repeated actions with limited progress over several months. Medicines audits were completed weekly and monthly, but duplication of information across records led to gaps in some audits. This meant that despite frequent checks, the process was not robust enough to identify and address all risks.

Action plans had long completion dates, for example, transferring care plans to the electronic system had been in place since February 2025 but was still incomplete and lacked key information and risk assessments. Overall, this meant risks were not consistently managed, improvements were delayed, and we could not be assured of safe, high-quality care.

The service was not fully embedded within the local community, and there was no meaningful community engagement. Staff engaged with healthcare professionals but did not consistently work effectively with all relevant external partners. Partners said they believed the registered manager and staff wanted to provide a good service, but staffing levels sometimes hindered communication and limited effective joint working.

The service did not consistently focus on continuous learning, innovation, or improvement. Although there was an intention to promote improvement, this was not embedded in practice. For example, improvements were not always identified, and when they were, actions were not consistently taken. Shortfalls were not rectified in a timely manner, and lessons learned were not effectively shared with all staff to prevent recurrence. Systems to measure outcomes and evaluate impact were limited, and improvements were not reliably sustained or achieved.