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 Inadequate. At this assessment the rating has changed to Requires Improvement. Further improvements were needed to ensure governance systems were sufficiently robust and embedded in practice.

The provider was in breach of the legal regulation relating to Governance.

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.

The previous registered manager left the service in February 2024. Following this a consultancy company was appointed by the provider to manage the service for a time limited period. There had been a lack of consistency in how the service had been managed throughout 2024. However, there was a new manager in post who started in August 2024 but had not yet been registered with CQC. The manager and provider confirmed that the culture within the service had improved. The manager told us, “We all work as a team, having an open-door policy and having staff feel they can come and discuss concerns has helped massively. More staff meetings are taking place and staff are speaking up in meetings.” Staff were feeling more supported in their roles, and they received regular supervision with the manager. A staff member told us, “I am very impressed with [manager] they listen, and any worries or concerns are dealt with quickly.” Processes were in place to help staff demonstrate a positive, compassionate, listening culture, focused on learning and improvement. The manager told us they were committed to improving the training opportunities which promoted further learning for all staff. The manager told us how they intended to improve opportunities for people to promote positive outcomes.

The manager was visible within the service and led by example to their staff team. One staff member said, “[Manager] is not afraid to work on the floor. They are visible.” The manager was able to identify and discuss priorities for the quality of the service and acknowledged there were still further improvements to be made. The manager had received 1 formal supervision session with the provider since starting at the service. The quality of the supervision was not sufficiently detailed, and it was important that the manager was provided with effective supervision and opportunities for development. This would also benefit the provider who would be able to assess their knowledge and progress with making the required improvements.

There were processes in place to encourage staff to share concerns and speak up. Staff told us that the manager was approachable and supportive. Staff were confident any concerns they raised would be acted upon. One staff member gave an example of raising a concern with the manager and told us how quickly the manager dealt with it. They said, “[Manager] is a breath of fresh air, and is very responsive.” People told us they felt confident speaking to any of the staff at the home, and that they would be listened to.

Staff told us they felt valued and respected in their roles, they were well-supported by the manager both professionally and personally. One staff member said, “It’s very different here now, we see the manager every day, and the provider is always here too making an effort, which is nice because I know them better now.” Staff told us, and we observed, that they worked well as a team, and they did what they can to help each other.

The provider had developed and instigated several governance and quality monitoring processes since our last inspection that had led to some improvements. However, these had not identified all of the areas of concern we identified at this assessment. Further work was needed to review the longer-term oversight of safety and quality at the service to ensure improvements were made, understood, embedded and sustained. Records were not always kept up to date or with the required level of information. Audits to review care plans were not effective as the service had not identified errors and inconsistencies we highlighted during our assessment. We found people's care records were not always accurate, and some required updating to ensure information about risk to people and others was known. Care plans were not always person centred. Recruitment records were disorganised and documentation by staff needed to be more accurate and detailed. Accident and incidents were recorded and there was evidence these had been reviewed. However, there was limited evidence of identifying themes and trends following on from an incident. The provider and manager responded to our concerns which included reviewing these areas, making improvements and planned further actions they would take. We will check for sustained improvement at our next assessment. The provider had reported notifiable events where required to the CQC. Staff understood their roles and responsibilities.

People told us they were supported to access health and social care services. Appropriate referrals had been made to external health and social care professionals where this was required for people. Health professionals told us they were involved in people’s care where required. One health professional said, “I have no concerns about the home and find the staff very caring, helpful and friendly. When I visit they always have a lead carer available and are knowledgeable about residents health problems and medication.”

The manager had a good understanding of how to make improvement happen. They recognised there was still much to do but prioritised the work appropriately. For example, the completion of people’s care plans and minimising potential risks. They were able to tell us about future improvements that would benefit people’s quality of life, such as ensuring people are supported to engage in hobbies, accessing the community, exploring people’s individual interests, and implementing a ‘Make a Wish’ tree where people can add their wish for something they may like to do, or something they may like to see in the service. The manager had sourced additional training for staff, and was keen to develop this further in time, to reflect best practice. The manager had been completing accident and incident reviews and was developing a system to analyse these for themes and trends.