Cherry Garth

Cherry Garth is a residential care home providing accommodation and personal care for up to 60 people. The service provides support to older people, people living with mental health conditions, people with dementia, physical disabilities and sensory impairments. At the time of our inspection there were 39 people using the service.

Accommodation is provided over three floors, divided into five areas which are each called 'houses'. Each person has their own bedroom, and there are communal toilets, bathrooms, lounge and dining areas. There is a hairdresser and a coffee shop. At the rear of the building, there is a garden and entertainment areas. Various offices for staff are located throughout the building.

People’s experience of using this service and what we found

People were not protected against avoidable harm. Medicines management was inadequate, and there were multiple medicines incidents. Incidents and accidents were not investigated in a robust way, and learning from events was not used to prevent recurrence of the same issue. Most people’s risk assessments were out of date and contained inaccurate or conflicting information. Not enough staff were deployed on some shifts. Relatives and staff commented on the impact this had on people’s care. Infection prevention and control was unsatisfactory. This placed people, visitors and staff at risk of infections. Actions to detect, investigate and report allegations of abuse or neglect were insufficient. Adults at risk were not effectively safeguarded.

Systems to assess, mitigate and review risks remained unsatisfactory. Although there was an action plan in place for improvements, the progress of addressing risk-based issues was too slow. The service had not properly ensured they were open and honest with people and relatives when safety incidents occurred. The service had failed to send legally required notifications to the Care Quality Commission (CQC) without delay. The workplace culture was viewed as unsatisfactory by care staff. Feedback from people, staff and relatives was collected and recorded by the service. However, analysis of the feedback was not completed in a timely way and improvements were not made based on survey results. Lessons were not learnt from the high number of falls and medicines incidents. The management and provider were working closely with the local authority and other partners to address failings.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 February 2020) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We also received concerns in relation to safeguarding people from abuse and neglect, falls, medicines incidents and governance of the service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

You can read our last comprehensive inspection report, by selecting the ‘all reports’ link for Cherry Garth on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

At this inspection, we have identified breaches in relation to safe care and treatment, safeguarding, governance, staffing, duty of candour and reporting incidents.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is inadequate and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in ‘special measures’ will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in ‘special measures’.

Cherry Garth is a residential care home and was providing personal and nursing care to 59 people aged 65 and over at the time of the inspection and can support up to 60 people in one adapted building. The service accommodates people across five different ‘units’ or ‘houses’ each of which has separate adapted facilities. Four of the houses specialises in providing care to people living with dementia.

People’s experience of using this service and what we found

We asked people about staffing levels we received comments such as, “No (not enough staff) quite a few staff have left”, “Probably on some occasions, (enough staff) but overall no. My wife often needs two people to help her. It would be lovely if there was more, but I am realistic it is all about budgets.”

Medicines were not managed safely. People did not always receive their medicines due to lack of stock. We found 13 people had not received their medicines due to insufficient stock. People’s allergies to medicines were not always recorded on the medicine record. Room temperatures were not being recorded for one unit and another unit recording was sporadic. Risk assessments and care plans did not provide staff with all the information they required to ensure people received good quality care.

The governance systems were ineffective and issues that had been raised by the provider had not been completed.

Staff received an induction when they started at the service. Staff training was not up to date and we could not be sure staff had the up to date skills and knowledge they required to carry out their role. Staff told us they knew what to do if they were concerned about people’s welfare. Staff told us they felt supported by the management team and had received regular supervisions.

We observed positive caring interactions between staff and people using the service. People were supported to attend external healthcare appointments.

Accidents and incidents were recorded, and action taken as needed. A complaints procedure was in place. Formal complaints were recorded and action taken as required.

People were offered opportunities to take part in regular activities.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update:

The last rating for this service was requires improvement (published 19 October 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to safe care and treatment, person centred care, assessing and mitigating risk, and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 14 and 15 August 2018 and was unannounced on the first day. We previously inspected the service in April 2016 and rated the service good at that time.

Cherry Garth is a ‘care home’. People in care homes receive accommodation and nursing or personal as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Cherry Garth provides care and accommodation for up to 60 predominantly older people, including those who live with dementia. The service accommodates people across three floors, each of which have separate adapted facilities. There were five ‘houses’ or ‘units’ three of which specialised in providing care to people living with dementia. At the time of our inspection there were 58 people living at the service.

At the time of our inspection the service did not have a registered manager in post.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, a new manager was in the process of applying to become the new registered manager.

Medicines were not managed effectively at the service. We found some people were without their medicines due to insufficient stock.

Risk assessments were in place for people with an identified risk such as repositioning due to frail skin and or fluid monitoring for people at risk of dehydration. However, some charts were inconsistent and some had not been completed for some time.

The service did not follow the requirements of the Mental Capacity Act 2005 (MCA). We did not find clear information in relation to people’s applications, reviews and expiry dates for standard Deprivation of Liberty Safeguards (DoLS). This meant people were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

We observed there were not always sufficient staff available to support people. We noted that staff were rushed and not able to spend time with people. Staff reported sometimes they do not get time for a break. We saw on one unit two members of staff were assisting a person in their room which left the floor unattended for some length of time. We pointed this out to the member of staff managing the service and they told us someone (member of staff) had gone off sick which left them short. However, people told us there were usually enough staff to attend to them.

Staff received training in safeguarding people from abuse and staff told us they would not hesitate to report any concerns regarding people’s welfare to the relevant authority.

Staff told us they felt supported and had received supervisions from their line manager. Appraisals had been carried out in line with the providers policy and procedures.

Auditing of the service and quality of care was completed. However, at the time of our inspection there were several incomplete actions outstanding.

People’s nutritional needs were met and appropriate measures were in place where people were at risk of malnutrition. However, some recording of people’s intake was not always documented. There was good partnership working with community specialists to monitor people’s well-being.

Some care plans we viewed were not current and specific to people’s current needs. We found conflicting information and changes to people’s support needs were not always documented.

People could attend activities and social events to provide social stimulation. The service employed activity coordinators to provide a programme of social events.

The service was cleaned to high standards to ensure people were protected from infection.

During this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We previously inspected the service on 2 May 2014. The service was meeting the requirements of the regulations at that time.

Cherry Garth provides care for up to sixty older people, some of whom may live with dementia. Fifty seven people were being cared for at the time of our visit.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

Overall we received positive feedback about the service. Comments included; "We are loved," "I'm very well looked after – no complaints," and that staff "Sort any problems out and get the job done."

There were safeguarding procedures in place and staff received training on safeguarding vulnerable people. This meant staff had the skills and knowledge to recognise and respond to safeguarding concerns.

Risks to people were identified and managed well at the service so that people could be as independent as possible. A range of detailed risk assessments were in place to reduce the likelihood of injury or harm to people during the provision of their care.

We found set staffing levels were adequate to meet people’s needs effectively. There had however been occasions when short-notice absences of staff had put pressure on other staff. The high level of commitment and team work of staff meant these situations had been managed in a way which kept people safe and with minimum disruption to their care.

Staff had been subject to a thorough and robust recruitment process. This made sure people were supported by staff that were suitable to work with them.

Staff received appropriate support through structured induction, regular supervision and annual appraisal of their performance. All the staff we spoke with said they felt able to speak with the registered manager or senior staff at any time they needed to.

We looked at records of training for all staff. We found there was an on-going training programme to ensure staff gained and maintained the skills they required to ensure safe ways of working.

Care plans were in place to document people's needs and their preferences for how they wished to be supported. These were up to date and subject to review to take account of changes in people's needs over time.

Medicines were managed in line with safe practices. Medicines storage temperatures had sometimes temporarily been above recommended levels although prompt action was taken to address this when it occurred.

The service was managed effectively. The provider regularly checked quality of care at the service through visits and audits.

We considered the evidence we had gathered under the outcomes we inspected. We used this information to answer the questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found-

Is the service safe?

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager told us three applications had been submitted to deprive people of their liberty. Appropriate safeguards were in place and up to date in each case.

We looked at care plans and spoke with staff. We found there were risk assessments in place to identify foreseeable risks to people's health, safety and welfare. Those assessments detailed how risks were to be eliminated or managed.

People who lived in the home said they felt safe and no one raised any concerns about their safety with us during our conversations with them. Those health professionals we spoke with had no concerns about the safety of people whom they had dealing with or arising from their frequent visits to the service.

Staff confirmed they had received training in safeguarding vulnerable adults, They had a good understanding of what constituted abuse and how they could recognise it. They told us they were aware of the relevant reporting procedure and we saw contact details for the local authority safeguarding vulnerable adults team were readily available to them.

Is the service effective?

We spoke with five people who lived in Cherry Garth. One person said, "This is my world now." They told us they were quite content with their care and how they were treated. They had a visitor who said they were encouraged by the way care staff interacted with their relative and felt they were "very comfortable". Another person who lived in Cherry Garth said, "I am very well looked after".

Throughout our visit, on each of the floors, we saw very positive interaction between staff and the people they supported. There was a calm atmosphere in the home. Call bells were answered promptly and were not intrusive. Staff appeared to have the time to engage in conversation with people and whilst busy did not give the impression of being hurried. This supported people in a way which was respectful and considerate as well as effective.

We looked at five care plans. One was for a person recently admitted. There was evidence of a comprehensive and thorough pre-admission assessment of the person's care needs. How those needs were to be met was set out in detail under a number of specific domains; for example, mental and physical health.

Following our visit we also spoke with a GP and a community nurse. They said communication was good. They had no concerns about the standard of care they observed. They told us any referrals to them had been appropriate and timely. This showed the home was effective in obtaining any expert medical support people required to maintain their health, safety and welfare. We saw medical visits and interventions were recorded in people's care plans.

Is the service caring?

One relative told us their relative had been able to choose the colour scheme for their room. They said they were kept informed about their relative's progress. They said their relative was happy and would certainly have told them if they were not. They said staff sat with their relative and reminisced; they did crosswords with them and did their nails. Another person who had moved their relative into Cherry Garth from another home, told us they were much happier with the standard of care they observed in Cherry Garth and they were satisfied staff genuinely cared for them.

Is the service responsive?

We looked at care plans for people who had been at Cherry Garth for a number of years. There was evidence that reviews of people's care had taken place. These involved the person concerned and/or their representative. This meant any changes to need could be identified and care plans and risk assessments amended to ensure they were still accurate and effective. It also showed care and support was planned and delivered in a way that was intended to ensure people's safety and welfare.

People who lived in the home told us they were able to attend meetings to discuss the operation of the home if they chose to. We saw minutes of a residents' meeting held on the 15 April 2014. This had included considering where they would like to go for outings during the summer. We also saw minutes of a social committee which included relatives and residents representatives. This showed people who lived in Cherry Garth and those who are responsible for them, were able to contribute ideas and make suggestions about key areas of the home's activity.

We spoke with an activity co-ordinator who told us care staff also provided activities for people either on a one to one basis or collectively on each unit. They gave an example of cooking, where staffing would be enhanced to provide sufficient, safe staffing levels. The activities programme for the home was displayed on each unit and on the reverse side of menus each day. Activities included trips out and made use of the home's gardens.

Is the service well led?

We saw analysis of the latest care rating survey results for the year 2013. This indicated 100% of respondents felt they were treated with kindness, dignity and respect and were 'overall' happy living in Cherry Garth. Where responses were less positive, there was evidence senior management had identified the actions needed to make improvements. For example in respect of the laundry service, access to senior Fremantle Trust management and people's recorded input into their own plan of care.

We saw detailed records of a comprehensive range of audits carried out at home and regional level on key areas of the home's operation and management. There was a themed audit plan in place for 2014 which included, for example, management of medicines, quality of management, safeguarding and safety and involvement and information. We also saw reports from Fremantle Trust trustee visits which included feedback received from people who lived in Cherry Garth and staff. This confirmed people who used the service, their representatives and staff were asked for their views about their care and support and they were acted on.

We saw there was a formal complaints policy and procedure in place and readily available. When asked, people told us they were very unlikely to make a formal compliant as they felt confident any concerns could be dealt with informally. The scope and scale of consultations, meetings and regular satisfaction monitoring in place, provided evidence of an open and accessible local and provider level management team.

Health professionals who had experience of the home told us communication was good and staff were capable and responsive. One person told us they were being assisted by staff to maintain their independence in some aspects of their medication.

Staff told us, and records confirmed, appropriate training was provided to support them provide care to a high standard. When we looked at people's care plans and medication records we found they were satisfactory. We saw there was a system in place to monitor and assess the standard of care, the experience of people who lived in the home and the systems and processes in place. Any concerns or failures in these were identified and changes made where possible to address and rectify them.

Throughout our visit we observed very positive interaction between staff and people who lived in Cherry Garth. There were activities taking place for those who chose to take part. We found meal times were pleasant social occasions and provided opportunity for conversation as well as food. One person we spoke with summed up what several people told us; "I am very happy here".

treated by staff and their involvement in making choices about their care. They also told us

about the quality and choice of food and drink available. This was because this inspection

was part of an inspection programme to assess whether older people living in care homes

were treated with dignity and respect and whether their nutritional needs were met.

We spent time observing care to help us understand the experience of people who could not talk with us.

The inspection team was led by a CQC inspector joined by a professional advisor.

During the visit, of the 54 people currently accommodated at the home, we spoke with five people in private and several others in the communal areas. People said that they were well looked after and their needs were met. People told us that they 'felt well looked after and involved' in their care. Others said 'staff do their best I can think of no obvious improvements'.

People said that they made decisions about where they wanted to spend their time. They

said that they had a varied menu choice and were happy with the food served.