Cherry Lodge

The provider was previously in breach of the legal regulation in relation to person centred care and governance. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

The environment was not always effectively maintained. We found on-going general maintenance repairs with, for example, some fire doors, radiator covers, unlagged hot water pipes and 2 windows without restrictors. The provider took immediate action to rectify some of these issues and repairs commenced during the time we were on site.

We found there had been some improvements made to the governance systems and audits in place to monitor the safety and quality of the care being provided. However, these new processes were not yet embedded into practice and had not identified the issues we found at this assessment.

We found the monitoring and recording of some medicines was identified as an area for some improvement, although, the overall management and administration of medication was safe. There had also been some positive additional improvements made at the service. Care plans were person centred and risk assessments contained instructions for staff on how to support people safely. There were some discrepancies between some care plans and risk assessments, however these were immediately addressed on the day. There had been an improvement to supporting people in their daily activities to meet their individual needs or preferences. Overall, staff had received appropriate training to support them in their roles; with the exception of training for sepsis which was immediately addressed by the registered manager. Generally, staff had been employed following a safe recruitment process. However this was not always consistent and there were areas, such as obtaining references and addressing gaps in employment history, that could be improved upon.

The provider had safeguarding processes to keep people safe. Incidents, accidents and complaints had been investigated and learning shared with staff to make improvements. There had been improvements made to mental capacity assessments being decision specific and completed in people’s best interests when supporting people to have some choice and control of their lives.