Cherington

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 inspection 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. We found a breach of legal regulation in relation to staffing.

This service scored 62 (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.

Any incidents or accidents were investigated and notified to the appropriate authorities. Incidents were analysed, reflected upon and discussed in handover meetings, staff meetings and supervisions, so lessons could be learned and actions taken to prevent reoccurrence.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Reviews of people’s daily notes and monitoring charts were undertaken to ensure care was being delivered consistently and in a timely manner. When people moved to a new home, a transition form was completed and staff from the new home would complete an assessment at Cherington. The registered manager told us arrangements would be made to ensure people had a minimum of 2 weeks’ worth of their prescribed medicines and information about people’s care and support needs was shared before they moved out.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

People and their relatives gave us mixed feedback when we asked if they felt safe. A relative said, “It’s very safe and secure. No-one can get in or out. It’s a good place, but it’s not the right place for her. She’s a quiet person with dementia and there’s people walking about and others shouting and swearing.” Another relative told us, “At times I think she’s a little neglected, but she’s safer here than she was at home. Sometimes the level of care isn’t satisfactory.” We observed occasions when staff did not provide the support people needed to ensure their safety. For example, 1 person was walking around the communal lounge, but there was no oversight from staff with regard to his mobility needs. This person approached another who had their legs stretched out and almost tripped over them. A relative intervened promptly and redirected the person away from the hazard. A few minutes later, the same person was walking towards a trolley where there were flasks containing hot drinks and which had been left unsupervised. We saw the person reach towards 1 of the flasks and a relative intervene to stop them. The staff member in the lounge did not observe this incident.

Staff completed safeguarding training and understood how to recognise and react to signs of potential abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We received a variety of responses from relatives when asked if they felt staff supported their loved ones safely. One relative said, “She can’t walk. They’ve got a stand-aid and a wheelchair. It’s an effort to get her up and I don’t think they bother much.” Another relative told us, “They hoist her. They use good practice, they know what they’re doing. They have in-house training; they’re well trained.”

Our observations in the communal lounge noted the lack of staff oversight in order to ensure people’s risks were mitigated. In 1 person’s falls risk assessment, we read there should be continuous visual monitoring, and for staff to intervene quickly if the person appeared unsteady or attempted to rise from their chair without support. Staff should avoid leaving this person unsupervised for extended periods. Whilst there was a staff member present in the communal lounge, they were busy attending to the needs of 14 people and could not provide the level of supervision this person required. A staff member told us, “Responding to call bells is an issue. There’s a risk of falls and risk of accidents. There are 2 residents from the top floor with low beds and they crawl on the floor. This happens sometimes.”

After our site visit, the registered manager told us they had permanently increased staffing levels so that there were now 2 care staff present in the communal lounge, rather than 1.

People’s risks were identified and assessed within their care records. People at risk of pressure areas were managed safely and nursing staff were knowledgeable and proactive in wound management.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff had completed fire safety training and audits demonstrated how fire risks, water safety and equipment were monitored and safely maintained. A contingency plan included information about maintenance, utilities, boilers, lifts, fire safety and floor plans for the management team to follow in the event of an emergency. The home provided an accessible environment with a lift to all floors, with ramps to the garden and through fire doors. Signs around the home enabled people to navigate safely. The communal lounge was situated on the ground floor, next to the dining room and quiet lounge. The communal lounge was an internal room, so there were no windows or access to natural light.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The majority of staff providing care on the day we visited were agency staff. The registered manager explained recruiting suitable permanent staff had been an issue. A relative said, “The issue is the high turnover of staff. The agency staff, I don’t know why some of them are doing the job. They don’t know what they’re doing, and they don’t care about people. The in-house staff are very good, but there’s too few of them. Sometimes, when it’s all agency, the level of care is terrible. People wait 2 hours to be taken to the toilet or wait to be changed when they’re wet. It’s not that the staff aren’t trying, but there’s usually only 1 person in the living room and there’s high needs in here. The weekends are chaos. There are fewer staff and lots of agency staff.”

One staff member said, “The main point is the shortage of staff. We have a lot of new people every day. Staff get shortened and delayed breaks; the management don’t see that. Hoisting, call bells, we are non-stop. Sometimes on a 12 hour shift I only have a lunch break all day. Residents come first; I can’t go and have a break.”

Staff training records showed several staff had not updated or refreshed their training in areas such as safeguarding and infection prevention and control. This put people at potential risk of unsafe care because staff were not up to date with their understanding and knowledge in certain topics. For example, 20 staff were overdue on their infection prevention and control training, including 5 whose training was a year overdue. The provider’s infection prevention and control policy states, “All new staff will receive training on infection prevention and control as part of their induction. Infection prevention and control training is mandatory. This means all staff must complete induction and an annual refresher in accordance with our training policy.”

Recruitment systems were effective, and appropriate checks were made to ensure new staff were safe and suitably qualified to work in a care setting.

After our site visit, the management team informed us they had reviewed staffing levels at the home. At the time of the inspection, there were 34 people living at Cherington, although the residents’ list we were given showed there were 33. Care staff numbers had increased from 7 to 8, with 2 on duty in the communal lounge. At night, an additional member of care staff was on duty, an increase from 4 to 5. Nursing staff during the day had increased from 2 to 3, with a supernumerary registered nurse engaging with people during mealtimes, and to assist with care planning and risk assessments. A review of outstanding training had identified where staff had not completed all that was required. Emails had been sent to staff who needed to update their training with a completion deadline of 31 December 2025.

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.

The home was clean and odour-free. People and their relatives provided mixed feedback. A relative said, "The cleaners are very good, but they’re overworked. The cleaner has 3 different jobs, she cleans, works in the kitchen cooking and works in the laundry.” One person told us, “It’s a bit behind at times, but it’s clean. They change the bed twice a week.”

The laundry was well managed with a sluice primarily used for the safe and hygienic disposal of human waste and contaminated water. Soluble bags were used in the washing machine to prevent cross-contamination and infection by safely containing soiled items. Laundry was collected from people’s rooms daily and washed immediately if soiled. Personal protective equipment was used by staff when delivering care.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

A relative told us, “The nurses are very good. They have 4 regular nurses. I can talk to them and they listen. They ring me, they’re very good. They tell me about medical changes and what the doctor recommends. Because I know when her medication is changed, I can understand any changes in her.” One person said, “A nurse brings me my medicines twice a day. They would tell me what it’s for if I asked.”

We observed an agency nurse giving people their lunchtime medicines. This was completed patiently and sensitively. Medicines stock levels were checked at every administration. Medicines were managed safely, including medicines which required secure storage. Staff competency to administer medicines was carried out. Monthly medicines audits were completed.