Cherry Tree Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm. The provider was previously in breach of the legal regulation in relation to medicines management.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. The management team listened to concerns about safety and investigated and reported safety events. Safety events such as accidents and incidents had been recorded. The management team had identified that the systems in place did not make it easy to identify patterns or trends meaning learning from accidents and incidents may have been missed. However, they had a plan in place to rectify this. Family members and staff confirmed they were updated following accidents or incidents.

The management team worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. Systems were in place to ensure continuity of care when people commenced a care service and there was involvement of the person, family members, external health or social care professionals. The registered manager undertook their own preadmission assessment to confirm the service was able to meet the person’s needs following admission and any required equipment was in place. Care files included a hospital pack containing relevant information if a person needed to be admitted to hospital or transferred to another service.

The management team worked with people, social and health care partners to understand what being safe meant to them and the best way to achieve that. The management team had taken appropriate action where necessary in response to safeguarding concerns. For example, the provision of 1 to 1 support for a person who was placing themself at risk. Staff understood their safeguarding and consent responsibilities. People and family members confirmed they felt safe. A person told us, “I think I’m lucky to live here. The good things are the safety and the care and the ability to be with other people or on your own. It’s run like a family.”

The provider usually worked well with people to understand and manage risks. Care files contained the majority of risk assessments relevant for the person. Where we identified some additional details were required the management team took prompt action to put this in place. For example, information about food and fluid texture in the assessment and care plan for one person was contradictory. Equipment to help manage identified risks such as movement alert equipment and pressure reliving equipment was in use where required.

The provider did not always detect and control potential risks in the care environment. We identified a possible risk from a low stair handrail. The management team undertook to take action to reduce the risk this posed to people, staff or visitors. There was also a concern about an external garage in an area not used by most staff or service users which required action. After the inspection the provider confirmed that the external garage was due to be removed. Although some adaptations to the environment had been made to support people living with dementia a formal audit of the environment to ensure it was dementia friendly had not been completed. The management team agreed to take action in respect of this. People had access to an outside garden area. A person said, “I like to go out in the garden in the summer. It’s delightful, lovely, an absolute joy.”

There were enough qualified, skilled and experienced staff who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs. Most pre-employment checks had been completed to ensure that staff were suitable to work with vulnerable people. Where we identified further evidence of good conduct in all previous care related employment was required the management team undertook to seek these additional assurances. People, family members, external professionals and staff members felt there were usually sufficient staff. A family member told us, “There’s enough staff on weekdays, there’s less at the weekends but you can always find someone.” Training was generally up to date and covered topics relevant to the service.

The management team assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The home appeared clean. Housekeeping staff told us they had clear routines to ensure all areas of the home were regularly cleaned. Staff had received food hygiene and infection control training. The home had been awarded 5 stars (the maximum) for food hygiene. Staff confirmed the availability of PPE and we saw them using this appropriately.

The management team had not always ensured that medicines were safe and met people’s needs. Most medicines were stored securely although we found the medicines fridge, which was in an area accessible to people and visitors was not locked when we arrived. Other than the medicines fridge, maximum/minimum storage temperatures for medicines were not being recorded. The provider promptly arranged to purchase suitable thermometers and subsequently confirmed these were in place. Where people were receiving ‘as required’ medicines the effectiveness/outcome of administration was not being recorded. There was no process to record the actual time of administration for regular dose medicines (eg paracetamol) meaning people were at risk of these being administered without sufficient time interval. The registered manager promptly introduced new systems. Staff responsible for the administration of medicines or topical creams had received appropriate training and their competency had been assessed. However, this and the providers audits of medicines, had not been effective as they had not identified the concerns we found. People and family members did not raise any concerns about medicines administration.