Cherry Lodge

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 requires improvement. At this assessment the rating has remained 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.

This service scored 56 (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 positive culture of safety and learning based on transparency. The provider listened to concerns and investigated safety events. We saw evidence of learning lessons from events, incidents, accidents and safeguarding concerns that had potential to put people at risk of harm. We found incidents and complaints had been investigated with the outcome discussed and shared with the relevant persons. The outcomes of the complaints and incidents were also documented, and actions had been put into place to mitigate future occurrence.

People and relatives told us they would raise any safety concerns with the registered manager and their team and felt they would be listened to and confident that action would be taken to address their concerns.

Lessons were shared at staff team meetings, handovers and in individual 1:1s. A staff member was open and transparent about their learning from specific events and demonstrated in their conversation with us, how they had put that learning into good practice. The staff member told us, “I shared my experience with the team because I didn’t want them to make the same mistakes I did and to show them how quickly things can progress.”

Historically, there had been issues concerning the administration of outdated medications following hospital discharges. We were told under the current leadership, those concerns had been fully addressed, and no further incidents had occurred. A healthcare professional told us there was praise for the current management team and the implementation of what ‘felt like more robust medication safety protocols.'

The provider worked with people, their family and friends and healthcare partners to establish and maintain safe systems of care throughout people’s care journey. We saw evidence of a collaborative approach to safety that involved people, where possible, and family, advocates and friends involved in the person’s care.

We spoke with 5 relatives during the course of the assessment. Two wanted to share their positive experience of their loved one’s referral and recent admission from the community and hospital admission into the service. One relative told us, “I cannot thank (the service) enough for what they have done for [person]. The staff are wonderful and the change in [person’s] life (moving to Cherry Lodge) has been good for them.” All the relatives told us they were kept up to date and felt informed and involved with the care and support of their loved one during the assessment and reassessment processes. There were processes to ensure people’s needs were assessed prior to moving into the home. Records demonstrated there was adequate information sharing for continuity of care, including when people moved between different services, which included hospital admissions due to a deterioration in their health. All the staff we spoke with knew people and their support needs well.

Health care professionals told us that under the current management team, there had been improvements made to the readmission processes when people had been discharged from hospital back to the service. For example, a more robust approach to re-assessing peoples’ support had been introduced to make sure the service could continue to meet the person’s care needs following a re-admission from hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Everyone we spoke with told us they felt the service was a safe environment to live in. People were seen to be comfortable around the staff supporting them. Relatives we spoke with did not have any concerns about abuse or neglect. When asked what it was like to live at Cherry Lodge, 1 person told us, “Safe comes to mind, everything is excellent. Since [Registered Manager] has been here, they are just the best manager (the service) has ever had.”

Staff understood the importance of escalating any concerns they might have if they thought someone was being abused. One staff member said, “I have completed my safeguarding training and know what to look for. If there was a resident that was acting differently, or pulling away from a certain staff member I would question that and raise it with my manager.”

We saw where people were becoming upset or anxious, staff were there promptly to offer reassurance and used distraction techniques such as a walk into the garden, or to play a game or a walk to the dining room for a drink. During our time on site, the home environment was calm and organised.

The provider had effective systems and process to make sure people were kept safe from potential abuse and neglect. We saw evidence of collaborative working between the service and partners, such as the local authority safeguarding teams. CQC had been appropriately notified of any potential safeguarding incidents. Staff had completed recent safeguarding training.

There were processes to make sure people’s human rights were met including the application and authorisations of Deprivation of Liberty Safeguards (DoLS).

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were people living at the service where their first language was not English. The provider had employed a number of staff from similar cultural backgrounds to support people and we saw some staff were able to converse with people in their own first language. The provider had taken some other measures to try and make sure communication was in an accessible format. This was through the use of flash cards and we were shown some cards were printed in different languages. However, during our site visits, we did not see these cards being used with people to support effective communication. For example, 1 person told us that one of the main things that caused them anxiety was not being understood. There were flash cards in this person’s language but it was not made clear to us how these were being used to communicate with this person. Staff we spoke with told us they were aware of the communication tools but were not able to provide us with an example where these tools were used and how effective they had been. We were told they had been used when delivering personal care in people’s bedrooms. This had not always been consistently evidenced in the reviews of people’s risk assessments, care plans or daily notes.

Where people lacked the mental capacity to understand potential risk, we found there had been appropriate mental capacity assessments completed, and a best interest decision process had been followed. Discussions had involved the appropriate agencies, the person’s family, friends or advocate.

People and the relatives we spoke with all felt staff were competent when supporting people with any potential risks, for example, transferring to and from a wheelchair and mitigating the risks of choking and falls. We found where it had been determined people had capacity to make decisions to being supported by the service; those people had been fully involved in managing their own risks. For example, 1 person assessed as high risk of choking had had discussions with the relevant professionals and agreed to a risk assessment being put in place when eating food. The person had been made fully aware of the increase in potential risk of choking and agreed to a referral being made to the Speech and Language Therapy team (SaLT). A staff member told us, “People have the right to make an unwise decision, and it is our duty to help them with that choice in the safest way we can.”

Some people could express distress of anxiety. Staff were able to explain how they supported people and it was clear they knew people’s care and support needs well. Our observations during the site visits found staff deescalated situations quickly and without restrictions.

We found staff were assigned specific areas around the home to make sure there was always a staff member with people. For example, communal lounges. When people were at risk of falling, staff would remind them to use their walking frame. Our observations confirmed walking frames were by people to support them with standing and moving around the home.

The provider had policies for staff to guide them on best practice in relation to, for example, choking, falls, diabetes and seizures.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People and relatives we spoke with had not raised concerns regarding the environment. However, during our site visits we found there were outstanding repairs to fire door frames that were damaged creating an uneven gap between the door and the door frame which meant they did not always fully close with an effective seal. The doors included people’s bedrooms and doors in the corridors on all floors of the service. In the downstairs communal bathroom, hot water pipes had not been wrapped with a protective cushion and there were radiator covers that had become detached from the walls on the ground and first floors. This exposed people to the risk of burns if they fell against the hot surfaces.

We identified other risks in the environment which exposed people to risk of harm. Two fuse cupboards had not had the padlock locked on the ground and first floor. In the stairwell there were two upper windows missing a restrictor to limit their opening gap. In the main reception area, there was a damaged radiator with sharp and jagged edges that had the potential to cause injury to people.

There were regular maintenance checks made around the building but those checks had failed to identify the issues found during the assessment. The provider started to take immediate action to rectify the concerns we identified.

The provider’s fire risk assessment completed in November 2024 had identified a door schedule should be implemented as a number of fire doors required maintenance to make sure they conformed to fire safety standards. The suggestion to implement a door schedule had also been identified in the November 2023 fire risk assessment, but this still remained an outstanding action.

Staff explained what they would do in the event of an emergency, for example a fire. Most of the staff had received fire warden training and there was at least one fire warden on duty each shift, day and night. There were personal emergency evacuation plans (PEEPs) in place for all the people living at the service and they had been regularly reviewed and amended in the event of people’s needs changing. We found there had been weekly fire alarm testing and there had been fire drills. However, we found that 3 staff on duty at night had not participated in a fire drill from at least 30 November 2023 and according to the provider’s records, the last night fire drill, took place on 29 May 2024. Fire drills should be conducted at least annually and the results should be kept as part of the fire safety and evacuation plan. Fire safety in the workplace: Fire safety equipment, drills and training - GOV.UK

Training records showed staff had completed appropriate health and safety training which included moving and handling and fire safety.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

People and relatives told us they felt the staff were trained to support them safely with their care needs. Staff explained their training induction into the service when they first started working there. One staff member told us, “We had to go through policies, learn how things are done in the home. We also completed a care skills course online, which I found really useful.” We found when reviewing staff training there was some improvement to be made around the training for sepsis as this had not been completed by all care staff. Sepsis can be difficult to identify, especially in care home environments. Sepsis training is crucialfor early detection and timely intervention and can help staff recognise signs and symptoms, leading to faster treatment and increased chances of recovery.

We reviewed the recruitment processes and found, generally, while staff had been recruited following the provider’s recruitment policy this had not always been consistent. For example, we noted on 1 file we reviewed a reference had been requested from a family member. It was not always clear where there were gaps in employment, whether these had been discussed further to ascertain the reasons for those gaps between jobs. Where poor performance had been identified, discussions to address the performance, had taken place. We found security checks had been made on staff members.

Staff told us they received support from the registered manager and their management team through regular supervisions and team meetings. Staff described the registered manager as ‘approachable’, ‘helpful’, ‘supportive’ and staff felt valued by them.

There were no concerns raised with us about the staffing levels at the service. During our site visits, we found there was enough staff on duty to support people in a timely manner. Call bells were answered promptly and the staff were organised in their duties around the home. There was a calm atmosphere.

There was an improved approach to assessing and managing the risk of infection to protect people. However, we found the provider had not always detected and assessed the risk of cross contamination. For example, some environmental factors could impact on the effectiveness of good infection control practices, such as, handrails on all floors, in parts, had paint flaking off them and needed repainting. Door frames and doors were chipped, possibly with knocks from wheelchairs, leaving the wood exposed and frames uneven. Walls also had paint chipped away that could affect the effectiveness of thorough cleaning. In the staff bathroom there was an unclean sink which staff used during their breaks. The staff bathroom was immediately cleaned.

Overall, the environment was kept visibly clean. There were no issues with the storage and cleaning of laundry. In June 2025, the kitchen had attained a food hygiene rating of 5, which is the highest rating a service can be awarded. The kitchen was clean and tidy and food was stored, prepared and handled hygienically. There was no clutter around the service. Staff had access to personal protective equipment (PPE) when they needed it. We found when reviewing people’s records, they were offered access to available vaccinations if they wished to receive them. Care plans also detailed the support people required to maintain their personal hygiene.

People, relatives and staff did not raise any concerns about the cleanliness of the home environment. There were cleaning schedules in place and we found people’s rooms were deep cleaned monthly, including curtain laundering and full room clearance. Equipment such as chairs and cleaning trolleys were washed regularly. There was a waste management process in place with waste being appropriately segregated and safely disposed of in yellow bins. All staff had completed recent infection control training and hand washing. Staff competencies had been checked through spot checks completed by the deputy manager or the registered manager.

The provider did not always make sure that medicines and treatments were stored safely and met people’s needs, capacities and preferences. For example, we found 3 bottles of medicine, that should have been recorded in a register, had not been added. We also found 1 bottle of medicine had been opened on 25 November 2024 that should have been disposed of in February 2025 and was last administered to the person on 11 April 2025. There was no harm to the person. There was also an overstocking of some medicine. We raised these concerns with the registered manager and they took immediate action to have the excess stock of medicine returned to the pharmacy. We also explained the importance of auditing medicines even if they were not being used by people but were being kept in stock.

People and their relatives did not raise any concerns with their medicines and were happy with the support they received from staff. We saw staff, where appropriate, had received medicine training and had their competencies assessed by the deputy manager or the registered manager. People’s medicine had been administered in accordance with their needs and had been recorded appropriately on people’s medicine sheets (MARs).

There were protocols in place for medicines required ‘as and when’. There were clear protocols in place for medicines that required to be administered covertly to people. We saw discussions had taken place with healthcare professionals, for example, the GP and pharmacist and with the family. Where the person lacked the mental capacity to understand the importance of taking their medicines, decisions had been made following the best interest process, in line with the Mental Capacity Act 2005 and recorded accordingly.

Feedback received from visiting professionals was positive. They all told us about the improvements the current management team had made. For example, the service’s approach to administrating medicines, especially when people returned to the service following a hospital admission. One professional told us, “Staff are much more competent [in medication administration and management] and protocols are followed correctly.” There was no evidence people were being over medicated when there were episodes of anxiety or upset. Staff used distraction techniques as the least restrictive option.