Cherry Lodge

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. This is the first assessment for this newly registered service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider was committed to equality of opportunity and providing a workplace for staff that was free from discrimination. This was reflected in the provider’s policies and procedures.

There was a stable leadership at the service with shared responsibilities to ensure good care delivery for people. The registered manager had the skills and experience to lead effectively. They did so with integrity, openness and honesty. The registered manager reassigned work to other team members making sure they developed in their role. This included staff taking on responsibilities to carry out regular checks and updates to people’s care plans.

At the last CQC assessment we found CQC notifications were not sent by the provider when required. At this assessment, the registered manager understood their responsibility to notify the CQC of events or incidents involving people and we saw a checklist displayed on the notice board to remind them about notifiable events to the CQC. Nevertheless, the checklist had not included the Deprivation of Liberty Safeguards (DoLS) notifications and therefore these were not sent to the CQC. The reasons for this were discussed with the registered manager and we were satisfied there had been some genuine confusion and oversight around the notifiable events. The registered manager has since submitted the relevant notifications and no further action was required.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People were asked for their feedback about the care delivery and the improvements they wanted to make to their daily living. An action plan was put together as a result of the questionnaires being completed by people, who made suggestions regarding their input with the menu planning and food shopping. The registered manager told us, “I get more feedback from the [people] than staff, they are able to voice out the issues.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us the provider had listened to their views which demonstrated their desire for people to achieve the best outcomes possible. Their comments included, “Management is very good. Yes, if we need support for anything, the [registered] manager provides” and “We do have supervisions and staff meetings to discuss any issues. The [registered] manager does respond well to what needs doing.”

Quality assurance processes were in place to inform improvements to the service. Regular audits were carried out in relation to people’s care records, health and safety and staff support. The management team reacted swiftly where an improvement was required and also identified during our visit. This was in relation to the CQC notifications, people’s living environment, care plans and management of medicines. We were satisfied that appropriate actions had been taken by the provider to ensure good governance at the service aimed at robust monitoring of people’s care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with people’s circle of support and collaborated for improvement. Family members told us they were involved in making decisions about their relatives’ care, commenting, “[The staff team] always lets me know if [my relative] has got an appointment or if there are any changes” and “I am very happy with [the registered manager], he always informs me if there are any changes. [The registered manager] is always happy to speak to me.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice. Since the last CQC assessment, actions had been taken by the provider to make the necessary improvements to the service delivery. This included updates to the paperwork for reporting incidents/accidents. Also, the service now completed their audits electronically to ensure the ongoing monitoring of the care being provided to people.