Cherrywood House

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders created a shared direction that made sure each individual person was at the centre of their support when decisions about their lives were being made. Information was shared with staff through handovers, flash meetings and safety huddle meetings.

The registered manager promoted organisational values; they had introduced a monthly team award which encouraged employees to nominate their colleagues for working in line with these values. The registered manager told us about work they had completed to improve the culture of the service following feedback received from staff.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. The registered manager told us they had support to undertake their role well from senior management through supervision, as well as peer support from other managers within the organisation. The registered manager encouraged staff members to develop by supporting them with opportunities to further their skills and training. For example, one staff member told us they had been enrolled on a course to further their learning and other courses they had already completed.

A person’s relative told us “The new manager is extremely good. They are very caring and wanting to do their best.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Procedures were in place for people, their relatives and staff to provide feedback and speak up.

There was a whistleblowing policy, and posters displayed informing staff how they could speak up with any concerns. Staff understood the importance of speaking up and confirmed they were encouraged to speak up in team meetings and they had received relevant training to support this.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Any additional support staff may need in their roles were explored as part of the recruitment process. Staff had the opportunity to discuss any concerns and share ideas of how to improve the service within supervision. Long service of staff was recognised and celebrated. Staff said they worked within a supportive team.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The model of care was not in line with current best practice guidance right support, right care, right culture, this was because the service was open before the guidance was released. The service had taken action to address this by accommodating less people than they are registered for. Three people had self-contained annexes. Most other people had a bedroom with an ensuite.

The service had recently recruited more staff and had reduced their use of agency staff. The registered manager understood their responsibilities in relation to their regulatory requirements around notifiable incidents.

There was an overarching quality assurance process which included checks carried out by the registered manager, regional manager and the quality team. There were a wide range of audits completed to monitor the quality and support the running of the service. However, we identified some further improvements were needed to ensure documentation such as mental capacity assessments were fully completed and up to date, and care plans and risk assessments were clear and comprehensive and contained sufficient information on the new computer system. The registered manager had an action plan they were working on to ensure the records were brought up to date and recorded all required information. We also found daily records for people required more detail to be added around how people spent their time.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People’s care records showed staff worked in partnership with a range of agencies and incorporated guidance into the care they provided. The registered manager had good working relationships with local health professionals and advocated on behalf of people to ensure they received effective health care.

A professional said, “The manager is always very helpful when I call, I am always given access to the notes I need and staff are available to answer any questions I have.”

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe and effective practice. Improvements to the environment had been made since the last inspection. The registered manager had an action plan they were working on with specific actions to improve the level of detail in people’s support plans, risk assessments and mental capacity assessments. Staff had completed various training courses to develop their skills and knowledge. The registered manager accessed additional training courses for their team. One person had been involved in the interviewing process of recruitment of new staff, this was something the registered manager hoped to continue and develop.