Cherry Tree Cottage

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm

The service was in breach of legal regulations in relation to safe care and treatment (Regulation 12) and staffing (Regulation 18).

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The service had an incident reporting policy from May 2024. This was due for review in May 2025, however there was no evidence that this had been reviewed at the time of inspection in February 2026.

There were 15 incidents reported during the last 2 years. Several of these were different staff members’ statements of the same incident. Two of these were self-harm incidents, 3 of these were incidents where clients had left the service without prior warning. Other incidents included a night staff member asleep and a suspected diabetes complication incident where 999 was called.

The service used a handwritten form to report incidents. Staff did not always know when to report incidents and what needed to be reported. Medication errors were reported on a different form. We saw that 3 medication errors had been reported throughout 2025 – all of these were reported as no harm to client.

We did not see evidence of investigations into incidents or discussions around lessons learned. There was one incident whereby a diabetic client needed support, but the staff member reported they did not know how to take a blood glucose reading. We did not see that this was acknowledged as learning for diabetes management on the incident form. However, the service informed us this would usually take place informally and verbally. The provider intended to set up a Significant Events Analysis procedure to formally investigate incidents and document these.

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The service took self-referrals. The admission process involved completing a 2 part assessment. Part 1 was completed by recovery workers prior to admission and part 2 was completed by recovery workers on the day of admission. Clients were then seen by the doctor on day of admission. Staff were completing part 1 assessments initially as standard procedure. However, we saw in meeting minutes that there should have been a telephone enquiry health questionnaire that was completed prior to Part 1 of the admission process taking place. The aim of this was to reduce the time taken to complete the full part 1 assessment if a client ended up not being suitable for the service. The provider identified that this had not been happening in a post-inspection audit and intended to change this so that the pre-admission process was more efficient.

However, of the 4 clients that were on site on the day of the assessment, 2 of them had commenced alcohol detox without a GP summary present. For a third client, it is unclear if the GP summary was received prior to or after detox commenced, as the date on the document provided was after admission to the service. Detoxing from alcohol requires a comprehensive assessment due to risks associated with physical health and pre-existing medication interactions. Lack of GP summaries meant that detoxes could have posed risks to clients’ health, as prescribers relied on self-reported medical information and were not able to corroborate this.

Additionally, we found inconsistencies in the completion of this paperwork, including incomplete alcohol intake assessments, missing physical health history and suicide risk assessments not being completed. This meant that clients begun alcohol detox without all of the required information and this could have posed risks to their health and wellbeing.

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

There were 13 staff on the training matrix. Of these, 92% had completed a module called “safeguarding adults certification”. A staff member we spoke to was able to identify different types of abuse.

There were 6 new staff members who were not on the list, and we were unable to confirm whether they had completed safeguarding training.

Clients were given information about safeguarding and how to raise concerns in their information pack on admission.

We were not assured that staff always fully assessed or documented clients safeguarding risks before admission. One client record had incomplete details regarding their children, meaning a fully comprehensive safeguarding risk assessment had not taken place prior to admission. Another client disclosed a history of abuse, and this was not expanded on in a more robust mental health assessment. Another client had a pending court date whilst staying at the facility which highlighted risk to others. There was no discussion of suitability for admission despite this in their admission paperwork.

The compliance rate for a module called “Assessing Mental Capacity” was 92%. A staff member stated that they can contact a mental health team to complete a capacity assessment if they felt this was required, and staff were able to identify that being under the influence of substances may impair capacity.

The service 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. .

Staff involved clients in their assessments prior to admission; however, not all assessment documents were completed.

We reviewed 4 client records. One client record had incomplete alcohol intake assessments, missing physical health information and a lack of care plan of how to address physical health concerns if the client were to deteriorate.

Another client reported they had attempted to end their life 5 years ago, but the suicide risk screen was not completed as prompted by the admission paperwork. There was no evidence of acknowledgement of this or a discussion with the client around this in the clinical decision feedback when they were accepted.

There were 4 clients on site at the time of the inspection. They informed us they did not know what their care plans were.

The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service was due a fire risk assessment the week of the inspection. Findings from this noted non-compliance with fire doors and training for fire evacuation chair training, substances hazardous to health not being appropriately stored, and boiler room requiring fire resistant boarding. Fire doors were also observed propped open during the inspection. There was an environmental risk assessment that was due for review in 2024, and we could not see evidence this happened. Portable Appliance Testing (PAT Testing) was also noted to be outdated. However, plans were already underway to address this at the time of the inspection.

The provider had a person employed to complete maintenance requests. Maintenance issues were usually reported in the weekly community group or verbally reported to the maintenance staff member if urgent. The provider previously had oversight of maintenance issues on a spreadsheet. However, this was not in use past August 2025 and more recently the service used a whiteboard in the office to track maintenance work. We were informed that due to the size of the service, this process worked well and there were no issues with the completion of maintenance jobs. Since the inspection, the provider told us they plan to begin using the spreadsheet again for larger maintenance jobs.

The service provided mixed-gender accommodation. All rooms either had an en-suite or a private bathroom nearby for privacy and dignity. Staff told us that mixed gender clients do not share rooms and they are spread out across the facility, in line with mixed gender accommodation guidance.

There were some bedrooms with 2 single beds in them. The provider informed us that nobody has shared a bedroom since the Covid-19 pandemic. They reported that clients are free to move bedrooms if they wish, and if risks are highlighted on admission, this is taken into consideration for room allocation. There was also a bedroom downstairs for disabled clients.

The service 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.

There were 19 staff members working for the service – the registered manager informed us the unit was fully staff with no vacancies.

There were 7 recovery workers, and 2 support workers. Other staff included 2 kitchen staff, an office manager and registered manager. There were 6 new starters, one of these was a compliance lead and the others were recovery or support workers. There are no clinicians based on site. There is 1 prescriber for the service who attends on the day a client is admitted to complete the pre-admission assessment process. The prescriber is accessible to escalate concerns to via the telephone.

There were staff members staggered in the unit throughout the day. The service then operated on 1 recovery worker from 9:30pm throughout the night until 8am the next day. We reported concerns around the use of 1 recovery worker per night and the implications of this, should there be an emergency. The service had a lone working policy, which involved staff wearing a pendant called a “lone working device”. These devices had a button on them that would activate an emergency response to a call centre, and the on call person (usually registered manager) could respond and manage the situation. There is a clause in the treatment contract that states the client agrees to adhere to this and this is regularly mentioned during community meetings, should they need to activate this if a staff member is unable to. However, if clients were in their bedroom at night, we were not assured they would be aware of and able to raise the alarm if the staff member were compromised in any way. We were told that there had been no adverse incidents as a result of this process, and that this worked well for the service.

There were also lone working risk assessments in the lone working policy; however, we did not see evidence that these had been completed within staff HR records and included the previous registered manager’s name. However, none of the staff members we spoke to felt this was a concern.

Only 4 staff were trained in the use of naloxone, a drug that reverses opiate overdose. None of these staff worked nights, which means we could not be assured that an opiate overdose could be managed on site quickly on a night shift. Similarly, there were 2 recovery workers that work nights whose mandatory training was at 46%. One of these staff was not trained in basic life support. This meant we could not be assured that skilled and experienced staff were running the unit at night. However, the provider has included this in their overall audit of the service and have produced plans to address this. We were assured that the rest of the staff had completed basic life support. Mandatory training did not include the use of assessment tools such as Severity of Alcohol Dependence Questionnaire (SADQ) or the Clinical Institute of Withdrawal Assessment (CIWA). This meant that we were not assured staff were appropriately trained to assess and manage detox. Staff reported to us that they were not signed off for training, and most of the learning was shadowing experienced staff, being observed themselves, and then being deemed competent. We did not have assurances that competency checklists were in place to manage this. The service identified that the induction and e-learning package required updating in their own audit of the service. We have received confirmation since the inspection that all staff are now trained in the use of naloxone and that detox training is being rolled out to staff.

Staff turnover was 5.56% in the 3 months prior to inspection. One staff member had left within the last 3 months prior to inspection due to stress and wanting to focus on their own recovery. Sickness levels were reported to be low.

We reviewed 5 HR records. All records had a contents page for what should be within the folder. None of these had everything that was required. All records showed lack of supervision, with the most recent supervision being completed in June 2025. Although DBS checks had taken place, where these disclosed findings of previous criminal activity, we were unable to receive immediate assurances on site from senior staff that risk assessments had taken place in response to the findings. However, we did receive these assurances post-inspection.

Staff we spoke to reported feeling well supported by the team.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service employed domestic staff that completed a deep clean of the unit twice weekly and bedrooms were deep cleaned after a client completed their treatment and left the service. Kitchen staff managed the cleanliness of the kitchen. The service appeared clean and tidy, and no concerns were noted during the inspection.

There were no formal infection prevention and control (IPC) audits taking place at the service at the time of the inspection. This meant that we could not be assured that there was adequate oversight of clinical areas and that there could be unidentified IPC risks. The provider has acknowledged the lack of IPC audits and informed us that they intended to address this.

People were not always involved in planning.

Review of people’s care records showed that medicines reconciliation (checking medicines are correct), was not consistently completed during the admission process. Although staff reported that medicines reconciliation and obtaining GP summaries formed part of this process, 2 people did not have GP summaries available, and their medicines could not be fully verified. In 1 case, the care record showed that a person had brought in medication belonging to someone else. A family member was contacted for clarification; however, no follow‑up was documented and a prescription was issued without confirmation that the medicine reflected the person’s established treatment.

Some prescription only medicines (POMs) had been administered following verbal instruction from a prescriber without a written Patient Specific Direction (PSD). Written authorisation was not provided afterwards. Several other POMs held as stock did not have written PSDs. POMs cannot be legally administered without appropriate written instructions.

Medicines were stored in locked cupboards and designated storage areas; however, fridge temperature records showed sustained periods where temperatures were outside the recommended range. No clients required refrigerated medicines at the time of the inspection. The service identified through their own audit that the fridge needed replacing and was in the process of doing this.

There were no controlled drugs (CDs) in current use. CD storage met legal requirements. Review of the CD register showed crossings out and altered entries; CD registers must contain clear and permanent records. Altered entries can prevent accurate identification of discrepancies during stock checks and increase the chance of misuse.

Monthly date checking audits were carried out. Some medicines were close to expiry and there was no system to highlight medicines approaching expiry. We observed an expired diabetic hypoglycaemia kit and expired lancet testing strips.

During observed medicines rounds, staff confirmed people’s identity and completed two‑person checks in line with the service’s policy.

The service had a booking in process for medicines brought in by people and medicines supplied through GP practices, community pharmacies, or the service’s usual pharmacy provider. Staff monitored stock levels and ordered further supplies when required.