Cherry Tree Cottage

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• 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

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 good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to good governance (Regulation:17)

We have not awarded this service a score for Well-led.

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

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider’s aim was to provide holistic recovery from substance misuse, among other types of addiction – the clients there at the time of inspection were detoxing from alcohol. Staff were clear about their responsibilities and how to work together to support clients throughout their alcohol detox.

Staff understood the challenges and needs of the clients. There were some staff employed at the service with lived experience of substance use. Client feedback confirmed that this helped them feel understood and evidenced that staff had a shared vision and culture of how to provide care for them.

The team had weekly meetings; however, these did not appear to include any discussion around contributing to the overall strategy and direction of the service. Staff were not receiving formal or regular supervision at the time of inspection – this is another missed opportunity to allow staff to feedback on service improvement.

We saw board meeting minutes from October 2025. However, there were no front-line staff present and we did not see evidence of any other initiatives to involve senior leaders with front-line staff to improve the service.

Not all leaders understood the context in which the service delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

A staff member told us that the director of the provider regularly attends the establishment. The registered manager had worked for the service for 3 years and had been in their current role for 18 months. Multiple clients gave positive feedback relating to the registered manager. However, we were not always assured that leaders had the skills, knowledge and experience to lead effectively. The registered manager in place at the last inspection in 2019 had a clinical background. Whilst this is not essential for this service type, we did not see evidence that this variance in skills and experience was acknowledged or risk assessed, to ensure client care remained consistent with this reduction in on-site clinical support. At this inspection, we found gaps in oversight with some aspects of governance, including quality auditing, clinical governance meetings and formal documented learning from incidents. We were also not assured the provider understood their duty regarding sharing information externally. However, the director of the service was attempting to address gaps in the service. A compliance lead was recruited before the inspection. Processes were underway to recruit for a new registered manager prior to the inspection, and a new registered manager was then appointed after CQC had visited the unit.

People did not always feel they could speak up and that their voice would be heard.

Staff we spoke to told us they felt able to raise concerns without fear of negative consequences but had not felt the need to. However, we were not assured that there were appropriate measures in place to allow staff to anonymously share concerns if they wanted to. Staff said they would report whistleblowing concerns to the CQC if they had any but did not mention any formal, in-house whistleblowing policies. There was not an allocated freedom to speak up staff member. Leaders did not always involve staff to discuss ways to improve the service. The service told us they did not complete anonymous staff surveys due to the size of their team and because they were open with each other. However, they said this is something that they may consider doing.

Clients had opportunities to give feedback on the service they received in a manner that reflected their individual needs. This was done via feedback forms. Feedback was shared with relevant staff where applicable i.e., to celebrate and acknowledge good work.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had received training in equality and diversity. This was mandatory, and compliance was around 85% due to 2 people not completing it. Staff we spoke with did not report any concerns regarding equality and diversity.

The service valued lived experience and diverse backgrounds. Recruitment processes were inclusive and differences were respected within the team. Staff were employed with a history of substance use and sometimes with a history of crime.

We were not assured that staff were receiving appropriate, formal supervision. Despite this, staff reported feeling well supported and valued members of the team and felt able to manage work and their personal lives. A staff member told us they felt the duties at work were delegated fairly.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The service did not have effective governance or management systems in place to monitor quality, manage risks or support sustainability. There was not a clear governance structure in place of what must be discussed to ensure that essential information, such as learning from incidents or complaints, was shared and discussed. There were no clinical governance meetings in place at the time of the inspection. This meant that there was a lack of oversight into the running of the service and improvements could not be identified, shared and implemented.

The service had multiple policies in place that were out of date and required review. However, we received confirmation after the inspection that these were up to date and reviewed.

Audits were not always completed at the proposed frequency set by the provider, including medicines and infection control audits. This meant that issues could not be identified and addressed so the service could be improved.

The provider did not always internally report incidents in line with their policy. The registered manager informed us of an incident whereby a client attended the local hospital and was too unwell to return to the service, therefore had to finish their detox in the hospital. There was another incident verbally recounted whereby another client had to go to hospital, but this was lower risk and they returned to the unit. We did not see evidence that these were incidents folder in line with policy. These incidents were also not reported to CQC in line with statutory requirements.

The provider did not keep a formal risk register. This meant there was a lack of awareness of risks within the service and no clear plan on how to address these risks, who was responsible for overseeing the risk or an expected completion date.

There was a lack of oversight into the management of staff. Supervision and appraisals were not regularly taking place or recorded. Therefore, we were not assured regarding staff support, performance and development. We reviewed HR records and found there were gaps in information such as references and interview notes. Initially, we were not assured that staff who had a history of crime on their DBS checks had appropriate risk assessments in place. However, we did receive these assurances after the inspection. We did not see evidence of lone working risk assessments if staff worked nights.

The compliance lead and newly appointed registered manager completed an internal audit of the service and have identified changes they intend to make to the service. This included the reinstatement of reflective practice, clinical governance meetings and significant event meetings to promote learning development. Also included was the review of policy and staff training, induction and supervision. They also intended to work with the prescribing doctor to streamline and improve the pre-admission and assessment process. We were told that the provider was considering the use of electronic client records and they intended to improve the handover process.

The service had a business continuity plan for emergencies such as adverse weather or illness outbreaks.

The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff had some links with external stakeholders in the community to support client’s recovery. They supported clients to attend community groups for substance misuse and told us they can support clients with where to go for support when their treatment finishes.

However, we did not see evidence of staff meeting with senior leaders or commissioners to give feedback to improve the running of the service.

Staff did not always liaise with the GPs of service users to obtain GP summaries as part of the admission process. Three of the 4 client records that we reviewed that had discharge plans. All 3 plans were missing confirmation that a doctors’ discharge summary had been sent to the client GP therefore, we could not be assured that the clients GPs were aware they had completed a detox or that there was a summary of treatment provided to clients.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We were not assured that learning and innovation was taking place at the time of the inspection. This was because we could not see any formal documented evidence of learning or discussions about change within the service.

We were not assured that staff were using quality improvement tools or audits effectively. We did not see evidence that the service contributed to research or external audits.