Cherry Lodge

Cherry Lodge is a residential care home providing accommodation and personal care to up to 27 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 24 people using the service.

The service is spread across a ground, first and second floor, and a passenger lift was in place to access each of the floors. There were communal areas that people could access, including a lounge and dining areas.

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

Actions to identify, investigate and report allegations of abuse were not sufficient. Incidents which indicated abuse had occurred had not been reported to the local authority safeguarding team. Reportable incidents had not always been referred appropriately to ensure external scrutiny of the home.

Risks to people were not robustly assessed and mitigated. Staff did not always have the information they needed to provide safe care because risks associated with people's care had not always been fully assessed. This included risks relating to falls, diabetes, behaviours of distress, and choking.

Improvements were needed to infection control practices in some areas of the service. Staff were observed to wear appropriate personal protective equipment (PPE) but disposal of this was not always in line with best practice to reduce the risk of infection.

Records did not reflect staffing numbers were adequate at all times, including in the event of an emergency. Staff received training relevant to their roles, but we were not assured that were applying the learning in the delivery of care. There was no system in place to check this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The system in place for recording people's nutritional intake did not support the staff to clearly monitor what people had eaten daily, including any snacks to encourage weight gain. Some referrals to specialist teams such as falls prevention and dementia support had not been promptly actioned.

The provider had not considered best practice for creating dementia friendly environments and we have made a recommendation about this.

Governance systems were not robust. The service was not using governance processes effectively to learn lessons or improve the service. The inspection identified six breaches of regulation as systems and processes were either not in place, or not robust enough, to ensure people's care needs were identified and people received safe care and treatment.

Medicines were managed safely, and staff were recruited with suitable checks in place.

We observed caring interactions between staff and people. Staff told us they were very fond of and cared about the people at the home. Staff knew people well and had established positive relationships with them. Feedback from 9 people using the service confirmed that they felt positive about staff and comfortable with them.

The registered manager and provider were responsive to the inspection findings and feedback and took some action after the inspection for the more urgent concerns identified. However, there were many on-going improvements which will need to be made to ensure people receive a safe and effective service.

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

Rating at last inspection

The last rating for this service was Good (published 6 March 2018).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service was alleged to have been a victim of abuse. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of the risk of abuse. This inspection examined those risks.

The overall rating for the service has changed from Good to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Cherry Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding procedures, management of risk, staffing, consent, governance and reporting procedures.

We imposed conditions on the provider's registration, which means we receive monthly data and action plans from the provider to assess if improvements are being made in a timely manner.

Follow up

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.

Special Measures

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 6 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.

We found the following examples of good practice:

People living in the home and staff were tested regularly for COVID-19 at the intervals stipulated by government guidelines. Relatives and friends visiting people living at Cherry Lodge were tested using rapid lateral flow tests (LFT). The LFT involves self-administering a nose and throat swab. The sample is processed on-site.

The service was proactive in securing good stocks of personal protective equipment (PPE).

The service was booking visitors in at a time that suited people and was spaced out to reduce the risk of potential infection transmission with other visitors. Visitors were also provided with appropriate personal protective equipment, including a surgical face mask, gloves and an apron. Visitors were escorted in and out of the building by staff to avoid access into other areas of the home.

People were also supported to stay in contact with their relatives and friends via telephone and video-calling. Rooms on the ground floor benefitted from large windows, which enabled people to receive window visits.

Most staff employed at the service had received training on infection prevention and control, COVID-19, and the correct use of Personal Protective Equipment (PPE).

Guidance was given to the service to enable them to strengthen and improve internal systems and processes. All recommendations were considered and acted on promptly.

Further information is in the detailed findings below.

The service provides residential care in one adapted building for up to 19 older people, some of whom are living with dementia. There were 16 people living in the service when we inspected on 6 March 2018. This was an unannounced comprehensive inspection.

We last inspected this service on 29 and 30 June 2017, the service was rated as Inadequate because we found the registered provider to be in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took urgent enforcement action to impose conditions on the providers’ registration, which stipulated that no new admissions to the service should be permitted without the written consent of the Commission. We also asked the provider to keep us informed of actions which had or were being taken to mitigate identified risks to the people they are supporting. We decided to impose these conditions on the provider’s registration to help ensure that people were no longer exposed to the risk of harm.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good. During this inspection on 6 March 2018, we found that significant improvements had been made towards meeting the requirements to help ensure that people received an improved quality of service.

Cherry Lodge has 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.

The people who lived in the service told us that they felt safe and well cared for. There were systems in place that provided guidance for staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe.

There were processes in place to ensure the safety of the people who used the service. These included risk assessments, which identified how risks to people were minimised. Environmental risk assessments and scheduled service plans were in place, but some were slightly out of date. At the time of this inspection, building work was being undertaken within the home that would require new safety certificates to be obtained on its completion. We were assured that all the required risk assessments, service plans and safety certificates would be obtained as the work allowed.

There were sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. We saw that recent recruitment files contained the records necessary to evidence that people were protected by staff that had been safely recruited. However, the registered manager had identified that some of the older files needed reviewing and this was underway. Where people required assistance to take their medicines there were arrangements in place to provide this support safely, following best practice guidelines.

When the building work is finished, redecoration throughout the whole house was planned. The registered manager told us that they would take the opportunity to ensure that the home was made more dementia friendly. This would enable people living with dementia to find their way around the building more easily and to identify their own bedrooms. This would increase their independence and help them to feel less anxious and more relaxed.

Both the registered manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager knew how to make a referral if required. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People were supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services. There were arrangements in place to make sure the service was kept clean and hygienic.

People’s needs were assessed and they received effective care in line with current legislation from staff that had the knowledge and skills they needed to carry out their roles. However, we found that although staff had dementia training, it would be beneficial to the people who live in Cherry Lodge if staff undertook more in depth dementia training as the number of people they were supporting to live with dementia was increasing. The registered manager acknowledged this was a training need and undertook to provide it. This will mean that staff will have a better understanding about supporting people living with dementia.

People were asked for their consent by staff before supporting them in line with legislation and guidance. People supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services.

We saw many examples of positive and caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff protected people’s privacy and dignity.

People received care that was personalised and responsive to their assessed needs. Care records have been updated and were sufficient to help ensure that people received care that was personalised and responsive to their needs.

Outings and in-house activities were offered to people, but people told us that they would welcome more activities and support to develop new hobbies. The registered manager told us that they had identified this need and had plans to make improvements in this area. People’s experiences, concerns and complaints were listened to and steps were taken to investigate complaints and to make any changes needed.

The registered manager had made sufficient changes and improvements within the service since they had taken over its management in December 2017, to give us confidence that the service was well led. People using the service and the staff told us that the new management team are open, supportive and displayed good management skills. There were systems in place to monitor the quality of service offered to people.

Further information is in the detailed findings below.

Cherry Lodge residential home provides accommodation and personal care for up to 19 people. At the time of this inspection, there were 19 people using the service, some of whom were living with dementia. Three of the 19 people were receiving respite care for a temporary period of time.

There was 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.

During this inspection we found significant shortfalls in the quality of the care being provided. We found the registered provider to be in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took urgent enforcement action to impose conditions on the providers registration which stipulated that no new admissions to the service should be permitted without the written consent of the Care Quality Commission. We also asked the provider to inform us in writing by 10 July 2017, that they had assessed and reviewed every person living in the service, including those people receiving respite care, in relation to their risk of the development and management of pressure ulcers, malnutrition, falls, and choking. This condition continues on a monthly basis, whereby the provider informs us of actions which have or are being taken to mitigate identified risks. We decided to impose these conditions on the providers registration because people may be exposed to the risk of harm.

People’s health, safety and well-being were at risk because the registered manager and provider had failed to identify where safety was being compromised. Risks in relation to falls, malnutrition and pressure area care were not being adequately assessed or monitored to ensure people were cared for in a safe way. There was limited guidance for staff about how to manage or reduce risk.

We found shortfalls in the way that medicines were recorded and stored. Documentation showed that people did not always receive the correct medicines as prescribed. Some medicines were not checked to ensure they were stored at a safe temperature.

We found that care plans that did not reflect people’s current needs. Care plans were not personalised to the individual. This meant that staff did not always have up-to date and clear guidance to help them support people in a way that took into account their preferences.

Robust quality assurance systems and audits were not in place to monitor the service provided to people, and so the provider was unable to identify shortfalls in the safety and quality of the service. The provider had not undertaken regular checks to ensure the quality of care or to use this to drive improvement. The registered manager had not notified us of serious injuries which had occurred in the service, which is required by law.

Staffing levels were not sufficient in order to meet the needs of people and keep them safe at all times. The number of staff required to meet people’s needs was not calculated based on the needs of people using the service.

Continuous supervision and control, combined with lack of freedom to leave, indicate a deprivation of liberty, and the provider had not applied for this to be authorised under DoLS. People were not supported to have maximum choice and control of their lives to support them in the least restrictive way possible.

The dining experience was not consistently conducive to an enjoyable mealtime and opportunity for social interactions, and we have made a recommendation about improving the dining experience for people.

The provision of activity was not sufficient to meet individual and specialist needs. However, the provider had taken steps to improve this.

Not all staff had received necessary training updates. Training sessions were being sought in areas such as safeguarding, risk management, fire safety, and dementia awareness. Staff told us that they had not received training in behaviour which challenges, and we have made a recommendation about this whilst appropriate training is sought.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

We spoke with seven people who used the service, one relative, the registered manager, the assistant manager and two care staff. We reviewed three people's care plans. Other records that we reviewed included staff rotas, minutes from meetings and the provider's policies and procedures.

We used the evidence we collected during our inspection to answer five questions.

Is the service safe?

People told us that they felt safe and the staff we spoke with understood their responsibility in relation to safeguarding vulnerable adults. The provider had policies and procedures in place to help protect people from the risk of abuse.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA), 2005, and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The MCA provides a framework to empower and protect people who may make key decisions about their care and support. The DoLS are used if extra restrictions or restraints are needed which may deprive a person of their liberty. At the time of the inspection the manager was in the process of submitting applications for people assessed as requiring this safeguard. We noted that they were following the correct procedure to apply for the authorisations.

People's mental capacity had been assessed by the management team, but his had not followed the two part test in accordance with the MCA. The registered manager told us that they and the assistant manager were to undertake training in relation to the MCA. They said that this would help to ensure that people's capacity was assessed in accordance with the law.

There were enough suitably qualified and experienced staff to meet the needs of the people who used the service. We noted that people were attended to in a timely manner and that nurse-call bells were answered quickly. There was an on-call system in place for staff to seek advice from the management team out of hours.

We noted that accidents and incidents were audited on a monthly basis to determine if there were any trends or patterns. We saw evidence that the assistant manager took action to help reduce any repeat occurrences.

There were effective procedures in place to manage and mitigate foreseeable emergencies. These included plans in place in the event of fire and the need to evacuate people.

Is the service effective?

We noted that nationally recognised screening tools were used in the assessment of people at risk from malnutrition and pressure ulcers. We noted that the results from these assessments adequately informed people's care plans. People at risk of developing pressure ulcers were positioned on air-flow beds and pressure relieving cushions. We saw evidence that sensors were used in people's individual rooms that alerted staff when people got out of bed. This meant that staff could attend to them in a timely manner and help reduce the risk of people falling.

During our inspection we noted that the provider worked closely with other health and social care professionals. These included the falls team, physiotherapists and dieticians. This meant that people received care and treatment from a multidisciplinary team that helped to address all of their needs.

Is the service caring?

We spoke with seven people who used the service and they all stated that they were satisfied with the care and support that they received. One person said, 'I am happy here and get good care. The girls (staff) are nice.' Another person said, 'I enjoy it here. It's not home but I get well looked after. The staff are very caring. They ask me what I want to do during the day. The food is good.'

We spoke with the relative of one person. They said, 'I am very satisfied with Cherry Lodge and the care that my (family member) gets. The thing that makes it really good are the staff and how caring they are.'

During our inspection we saw that the staff were compassionate, and knew the needs of the people they cared for well. Staff told us about the different communication techniques that they used to help sure people understood what was being said. We noted that these were used effectively. Staff promoted people's independence whilst ensuring they received adequate support. The care given was not rushed and people were encouraged to take their time in order to achieve what they wanted to do.

Is the service responsive?

People's care plans responded to their individual needs. These related to all activities of their daily living. The service was responsive to people's social, emotional and spiritual needs. The activities that were offered to people reflected people's preferences and interests. The people we spoke with told us that staff assisted them to go outside if they chose to do so. This meant that people's inclusion in the community was promoted.

Residents and relatives meetings took place every two to three months. There was also a satisfaction survey for people to complete to determine their thoughts and comments about the service. We noted that people's views and comments were acted on. The provider responded to what people thought and this was evident through the recent redecoration of the communal areas and the change in menu choices.

The service had not received any written complaints but we noted that any verbal complaints that were received were documented and appropriately investigated. We saw evidence that the provider took account of comments and complaints to improve the service.

Is the service well-led?

The assistant manager told us that they were about to undertake the training to become the registered manager for Cherry Lodge. They told us that they received good support from the provider and registered manager.

All of the staff we spoke with told us that they felt well supported. They explained that the staff meetings that they had attended were productive. They told us that any new ideas that they suggested to help improve the service were taken on board by the management staff.

We observed a positive culture within the service. Staff worked together as a team and helped each other appropriately.

The service had quality assurance systems in place to assess and monitor the quality of the service people received. We noted that there were action plans to address any identified shortfalls in service provision.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service caring? Is the service responsive? Is the service effective? Is the service well-led?

This is a summary of what we found;

Is it safe?

We found there to be overall improvements in the way medicines were recorded, administered and stored.

Is it caring?

We noted only some staff authorised to handle and administer medicines had so far had their competence assessed to ensure they safely managed people's medicines

Is it responsive?

Is it effective?

We found some supporting information about people's medicines was in need of updating.

Is it well-led?

We noted there to be internal monitoring of medicines and their records.

During our inspection on 16 April 2014 we found that improvements had been made.

We spoke with six of the people who used the service. We gathered evidence of people's experiences of the service by observing how they spent their time and we noted how they interacted with staff and other people who lived in the service. We looked at five people's care records. Other records viewed included health and safety checks, the provider's quality monitoring audits and staff recruitment records.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information we had gathered to answer 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?

Our previous inspection in February 2014 identified and raised issues in relation to how the service managed people's medicines. At this inspection 16 April 2014 our pharmacist inspector again assessed if people's medicines were being managed safely and if arrangements were in place to protect people against the risks associated with the unsafe use and management of medication. We conducted a sample audit of medicines and found improvements in records but with some minor discrepancies and still some gaps in the records so we still could not be assured people were being given their medicines as intended by prescribers. We found that some medicines were still not being kept securely. We found staff authorised to handle and administer medicines had recently been provided training in relation to medicine management.

We noted that improvements had been made to the environment since our last inspection. The provider had taken steps to ensure that people were cared for in a clean environment and to ensure the risk of infection was reduced. We found the environment to be clean and there were records which related to infection control audits and cleaning schedules were in place to ensure that each area of the service was regularly cleaned.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had been submitted, the service had policies and procedures in place. Staff had been trained in understanding the Mental Capacity Act 2005 (MCA). This enabled them to understand when an application should be made, and how to submit one to the local safeguarding authority.

We observed there to be enough staff on duty to meet people's needs. Following our last inspection the provider had increased night time staffing levels from one to two staff to ensure that there was sufficient numbers of staff on duty to people's night time care needs.

Is the service effective?

People we spoke with told us their needs were met. We observed staff caring for people in an appropriate manner and offering them choices. The manager and staff spoken with and observed showed a good understanding of people's needs and acted in accordance with people's wishes. We looked at five care plans which told us about people's needs and how staff should meet them. People's needs had been regularly reviewed to ensure that the care being provided remained appropriate and to help staff identify and respond appropriately to changing or unmet needs. Staff consulted with family members and other medical professionals when required and this was recorded.

Is the service caring?

Our observations showed that the majority of people were happy living at Cherry Lodge. We saw that staff interacted with people in a caring, respectful and professional manner. One person told us, 'They are all kind to you. We have a laugh.' Another person told us, 'I have no worries or concerns. The food is good and I like to have meals in my room and they don't mind.'

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

Following concerns identified at our last inspection 05 and 06 February 2014, the provider had implemented new care planning documentation which described people's care and support needs in a person centred way. We saw that people's needs had been re-assessed. Daily records evidenced that where concerns about the health and well-being of people had been identified appropriate action had been taken to ensure they were provided with the support they needed. This included access to health care professionals such as a doctor, district nurse, dietician and chiropodist.

We saw staff responded to people's requests. One person told us, 'Things are getting better around here. Staff respond much quicker when I need help during the night. If I am worried about anything the manager will get things sorted for me.'

People who used the service were generally provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

In consultation with people who used the service and their relatives, we saw that care plans had been improved since our last inspection to record people's choices, describing how they liked to spend their day including their likes and dislikes. These were written a person centred way. We saw that care plans were regularly reviewed.

Is the service well-led?

Our observation of records showed that the provider had recently implemented management quality monitoring systems. The records we viewed showed that the manager had regularly monitored the cleanliness of the environment. Care plans and monthly medication audits had been carried out.

We spoke with eight people who lived at the service. We also spoke with one a relative and a health care professional that were visiting the home at the time of our inspection.

One person said, 'I cannot grumble they do their best, some of them are angels.' Another person told us, 'If I am unhappy about anything I go to the office and they sort it out for me. They know me well and they do their best.' Two people we spoke with told us they did not have access to regular baths. They told us they had recently gone without a bath for up to three weeks.

We looked at the care records of five people who used the service to establish whether their care needs were met. This included a review of the systems in place for managing people's nutritional needs. We found that there was a continued shortfall in effectively managing, the risks to people assessed as at risk of malnutrition, falls and pressure sores.

We carried out a tour of the building which included communal areas, all bedrooms, the main kitchen and the only bathroom currently available for people to use. We saw that in the main the premises and equipment were clean.

Our pharmacist inspector assessed if people's medicines were being managed safely and if arrangements were in place to protect people against the risks associated with the unsafe use and management of medication. We found the provider had ineffective systems in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

We spoke with four staff, the provider, the registered manager and the deputy manager.

We found that people were happy with the care they received and were asked for their consent before the staff performed a task. People's individual needs had been assessed but this had not always been completed prior to them using the service. Risks to people's safety had been assessed but these were not always reviewed in response to people's changing needs.

People liked the food and told us they had a choice of food and drink. However, the provider did not always take the proper steps to protect people from the risk of malnutrition.

The majority of the service was clean. However, one area of the service had an offensive odour and some equipment was not clean.

People told us that the staff were caring. The staff told us that they were happy working for the service. We saw that they had received training and supervision. However, the provider did not demonstrate that they were carrying out all of the required recruitment checks to ensure that the staff they employed were of good character.

Some records relating to the people who used the service were inaccurate. The care records contained inconsistent information. Not all records were up to date and some could not be located when required.