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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the provider had a vision and strategy based on transparency, equity, equality and human rights; they did not always understand the challenges in developing a structured plan to deliver this goal and how they wanted to improve and grow the service. The nominated individual for the provider (NI) holds the overall responsibility to make sure staff and leaders actively promote, safe, high quality compassionate care. It is also their overall responsibility to make sure the leaders they appoint to support them with this vision are suitably trained and have the acquired knowledge of current best practice, guidance and legislation relevant to the service. However, we found promotional audio visual aids developed to promote the direction, vision and values of the service were not appropriate to the audience and contained references to legislation that was not relevant to the regulation of health and social care in England.

Leaders encouraged and operated an open culture and had a vision that was shared with staff. The conversations we had with staff supported that there was an open culture within the service. Staff told us they felt well supported by the provider and the management team and were clear about the value of the service they provided to people. One staff member said, “We have great staff, work together well, always communicating. We understand each other. Staff will help each other across floors if they have less work to do.”

People and their relatives were happy with the care and support.

Health and social care professionals provided positive feedback about the care and support provided to people.

Staff and management fed back passionately about the care being delivered to people and spoke fondly of the people they were supporting. Staff told us they would report to the provider any poor practice and were confident concerns would be acted on by the management team.

The provider responded positively to the feedback we provided and demonstrated a willingness to make the improvements needed.

While the provider had inclusive leaders, not all leaders understood the context in which they delivered care, treatment and support. For example, referring to incorrect legislation within their policies and promotional material. Leaders had the skills, experience and credibility to lead effectively. Leaders were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. There had been a stable management and staff team for the last 12 months. Where areas of concern were identified, managers were open, honest and committed to making the required improvements. Staff knew their roles, responsibilities and how to support each other. Relatives spoke highly of the staff and management team.

Recruitment records were not always complete with appropriate references not always obtained for staff, in line with the provider’s own recruitment policy. Gaps in employment had not always been explored and explained. The provider took immediate action to address this at the time of the assessment.

Staff spoke positively about the service and the provider. They told us the provider was always accessible to them and there was ‘always an open door’. All staff we spoke with felt they could speak to the management team regarding any concerns or questions they may have and they would be answered and acted on promptly. One staff member told us, “The best thing about working here, there is great management, (registered manager) is always there to give support. My team are amazing. It's such a great place to work. Everything feels effortless. Everyone is good at communicating.”

People and their relatives told us they were happy with how the service was run.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People told us they would speak up and felt their voice would be heard. Staff were provided with the relevant policies and procedures detailing what was expected of staff working for the service. There was a whistleblowing policy in place and staff were aware of this and the procedures they needed to follow. Staff told us they felt able to raise any issues or concerns, including poor practice. Staff were confident the provider would listen to them. They advised us the management team were always accessible to them.

During the assessment process, the provider was open and transparent and took on board the findings of the assessment.

We were told by people the registered manager had a calm manner and spoke to people and their relatives with kindness. One person said, “(Registered manager) is the best manager this place has ever had and I’ve seen a few come and go."

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 felt listened to by the provider. The provider took steps to ensure staff felt that they were heard by the provider and were confident to raise any concerns they may have.

The provider ensured they were regularly available to staff, arranging supervision meetings and team meetings providing staff with the opportunity to engage with them, feedback on lessons learned and the general day to day operations of the service.

Staff told us they were happy working for the provider and felt they were treated fairly. There were procedures in place to consider staffs’ individual needs and ensuring all staff were treated equitably.

The provider had clear responsibilities, roles, systems of accountability or good governance. However, these needed to be applied consistently to ensure the provider had the best information about risk and performance.

At the time of this assessment, the provider had engaged the services of an independent consultant to support them with improving their systems and processes. There had been an improvement from their last inspection with regards to the monitoring of the service. However, historically, the provider has made improvements in the past only to slowly deteriorate again when there has been a change of leadership at the service. While these new processes had made a positive difference to the governance of the service, the processes and systems needed more time to become embedded into day to day practice.

We saw, care plans were more person centred and regularly reviewed. Risks had been clearly documented in people’s care plans with directions for staff to follow in the event of people falling ill, for example, seizures, choking and low blood sugars. People and their relatives and friends had been more involved in assessments and reviews of their care and support. There had been improvements made to social activities for people. There had also been improvements made to the monitoring of the service through the provider’s audits. However, audits had not identified some of the issues we found such as the overstocking of some medicines and building maintenance. The provider took immediate action to address some of the issues we identified on our site visits, with plans for refurbishment intended for the future.

Overall, where audits and checks had been completed, these had been effective and provided some oversight of the service for leaders. For example, following a complaint, an improved system had been introduced to monitor call response times which ensured staff attended people quickly when they activated their call bell.

Accidents and incidents were now routinely analysed for lessons to be learnt. Safeguarding concerns had been reported to the appropriate local authority and had been thoroughly investigated by the provider and notifications had been submitted to CQC as legally required to do so.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider was working well with healthcare colleagues to continue developing the working partnership to make sure people’s individual needs were being met.

The provider had systems and processes in place to record contact with health and social care professionals and would make referrals where appropriate.

The provider’s vision was focused on continuous learning and improvement across the service. The improved systems and processes put in place by the current management team to monitor the safety and quality of people’s care, and learn from incidents, accidents and safeguarding events, had been shared with staff and mitigation put in place to reduce risk of occurrences. However, these processes were new to the service and required time to become embedded into practice. For example, there had been missed opportunities to improve the environment within the home.