About the service: Cherry Tree Lodge provides accommodation and personal care for up to 72 people, some who are living with dementia and some who are very frail and have physical support needs. The service consists of four separate units over two floors. There were 53 people living in the home on the first day of our inspection visit, the 19 February 2019. There were 52 people living in the home when we returned on 28 February 2019.

People's experience of using this service:

•Systems to identify people's individual safety risks and to promote people's safety were inadequate.

•Good governance of the service had not been maintained because too often there had been inconsistency in the management team which meant there was a lack of responsibility to identify the shortfalls we found, including risks to people's safety and welfare.

•The provider's quality assurance systems were not effective in identifying, responding and maintaining a good standard of service that people deserved.

•No or limited action had been taken when quality assurance checks identified people could be exposed to unnecessary risk, such as potential skin damage because risk assessment tools were not being completed accurately or staff were not recording care interventions to manage identified risks.

•There were not enough sufficiently-skilled, senior staff to review everyone’s risk assessments to ensure effective preventative measures were in place for people.

•Staff had not had the training or support they needed to assist them in accurately identify emerging risks so support could be sought from community healthcare professionals.

•Community healthcare professionals raised concerns about the timeliness of referrals and the accuracy of the information they were given when a referral was made.

•On the first day of our inspection visit there were not enough staff with the appropriate skills, experience and knowledge of people’s individual needs to provide safe and effective care. Staff were not always available in communal areas so people could get assistance when needed. On the second day, staffing numbers had increased but there was still a reliance on agency or very new senior staff.

•Overall, people received their medicines as prescribed but improvements were required in the management of prescribed medicines applied directly to people’s skin.

•People’s dietary needs, preferences, likes and any allergies, were assessed and recorded when they moved into the home. However, people on modified diets did not always get a choice of what they wanted to eat and there was a lack of fortified snacks for those people identified as being at risk of losing weight.

•Improvements were needed to ensure people were supported to enjoy a wider range of activities on the individual units which reflected their interests, and enhanced their lives.

•Overall staff worked within the principles of the MCA in their interactions with people.

•Most staff were caring in their approach, but the main interaction with people was focussed on when they offered support or completed a care task.

•People's privacy and dignity was not always upheld.

•Improvements were required in the oversight and management of staff’s practice to ensure people received a quality service.

Following our inspection, we notified relevant stakeholders such as the Local Authority Quality Team about the areas of concern we identified.

We reported that the registered provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were:

Regulation 9 Regulated Activities Regulations 2014 - Person centred-care

Regulation 12 Regulated Activities Regulations 2014 - Safe care and treatment

Regulation 17 Regulated Activities Regulations 2014 - Good governance

Regulation 18 Regulated Activities Regulations 2014 – Staffing

Rating at last inspection: Requires Improvement. The last report for Cherry Tree Loge was published on 6 March 2018.

Why we inspected: This was a planned

This inspection took place on 4 January 2018 and was an unannounced visit. We returned announced on 11 January 2018 so we could speak with more staff and to look at the provider’s quality assurance systems.

At the last comprehensive inspection on 6 December 2016, the service was rated as ‘Good’ overall, but we found a breach of Regulation 17, good governance under Well led. We completed a follow up inspection in June 2017 to review the area of Well Led and found sufficient improvements had been made, so the provider was no longer in breach, but the rating remained ‘Requires Improvement’ in Well Led. This was because there was no registered manager in post and audit systems still required improvement.

This inspection visit was a comprehensive inspection and we checked to make sure improvements had been made in Well Led to a least ‘Good’. Whilst some improvements had been made, we found some improvements were still needed in audit systems because the provider had not identified some of the improvements we found, and there continued to be no registered manager.

A requirement of the service’s registration is that they have 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was no registered manager in post. The last registered manager left the service in March 2017. Since then, two managers have managed this service but had not registered with us and have since left this service. A new manager was appointed to the home in December 2017 and was in the process of applying to become the registered manager at the home.

The Lawns is a care home registered to provide care to 76 people. People in care homes receive accommodation and nursing and/or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection visit, 59 people lived at the home on 4 January 2018 and when we returned on 11 January 2018, 58 people lived at the home. Some people at the home were living with dementia. People are supported across two floors and both floors support people living with dementia.

People told us they felt safe at the home, because they felt safe with the staff who supported them. However, since June 2017 some people’s personal, valuable and sentimental items had gone missing. Police and safeguarding had been involved regarding the potential thefts but we could not be confident the provider had taken necessary steps to protect people from financial and emotional abuse.

The provider used recognised risk assessment tools to identify any risks to people’s health and wellbeing. Staff knew how to support people to reduce identified risks to people. However, further checks were needed to ensure people’s records provided staff with the necessary information to keep people safe, especially when people’s needs or behaviours changed.

People told us their needs were met because they were supported and cared for when needed. People were complimentary of the staff and said staff were kind, caring and considerate in their approach. People spoke positively about the friendliness and willingness of staff to help them.

People told us they had a choice of meals and could eat in the dining room or their own bedroom, according to their individual preference.

People’s privacy and dignity was respected and staff knew how to maintain this to prevent people feeling uncomfortable. Staff promoted people’s choices and independence which gave people a sense of worth and ownership in how their care was delivered.

The home was clean, free of odour and staff wore personal protective

We carried out an unannounced comprehensive inspection of this service in December 2016. At that inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and issued a 'requirement notice' to the provider, requiring them to make improvements in how they checked the quality of the service provided and made improvements as a result. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the regulations.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Lawns on our website at www.cqc.org.uk.

At our previous inspection in December 2016, we gave the home a rating of 'Good’. However, we

found the provider was in breach of Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider’s quality assurance systems and management of the home was not effective in identifying and implementing improvements. Constant managerial changes has had a destabilising effect on driving and sustaining improvements. At this inspection, we found some improvements had been made. This meant the provider was no longer in breach of the regulation although further improvements were still required to ensure the governance of the home supported a good quality and well managed service.

The overall rating of Good, which was awarded following the CQC's previous inspection of 1 and 6 December 2016, was not correctly displayed. We discussed this with the manager and regional care director who displayed the correct rating poster whilst we were in the home.

The home is required to have 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 and associated Regulations about how the service is run. At the time of this inspection the home did not have a registered manager in post. A manager had been appointed in April 2017 and was in the process of registering with us.

Some staff said the number of managerial changes ‘were tiring’ and felt changes were made because it was another manager, rather than for the good of the service. Staff felt the previous manager was not supportive and said they did not feel comfortable raising suggestions or giving feedback. This time, staff were complimentary about the new manager and said the team was becoming more cohesive, but they wanted a period of stability for the people using the service and for them. The manager said recent changes in staff personnel had taken place and those changes meant staff morale had improved which was supported by what the regional care director told us.

Improvements to the quality assurance systems were being made but when checks were delegated to others, there was no effective system to follow up on these improvements. We found some checks were being made without understanding and questioning, if they were required. The regional care director agreed to relook at their quality assurance processes and focus more closely on how their audits increasing the quality of service provided.

The inspection took place on 1 and 6 December 2016. The visit was unannounced on 1 December 2016 and we informed the operations director we would return on 6 December 2016 to speak with the registered manager.

The Lawns is a residential home which provides care to older people including some people who are living with dementia. The Lawns s registered to provide care for up to 76 people. At the time of our inspection there were 54 people living at the home.

This home was last inspected in December 2015 and was rated as ‘requires improvement’. We found a breach of the regulations relating to the governance of the home. At this inspection we found improvements had been made, although we found some improvements where still required in the management and governance within the home. The provider had not always followed their action plan to ensure improvement actions were taken and sustained.

A lack of consistent management of the home, meant some of the quality assurance systems were not thorough or regularly checked. When some monitoring or management checks were delegated to others, improvements did not show what action, if any, had been taken to improve the delivery of service. We could not be confident statutory notifications involving serious incidents and safeguarding concerns had been sent to us.

The home had 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 and associated Regulations about how the service is run.

People and relatives were complimentary about the care and support they received. People received care that enabled them to live their lives as they wanted and people were supported to remain as independent as possible. People were supported to make their own decisions where possible and care was given in line with their expressed wishes.

Care plans contained accurate and relevant information for staff to help them provide the individual care people needed, although some care information required updating, such as people’s assessed dependencies which determined the levels of care needed.

People’s care and support was provided by a staff team who were knowledgeable, trained and knew people well.

People were encouraged and supported by a caring staff team. People told us they felt safe living at The Lawns and staff knew how to keep people safe from the risk of abuse. Staff understood what actions to take if they had any concerns for people's wellbeing or safety. However, we found two examples of potential safeguarding incidents that the provider had not reported to the relevant authorities.

Potential risks were considered positively so that people did things they enjoyed. People were encouraged to maintain relationships and kept in touch with those people who were important to them.

Staff received essential training to meet people’s individual needs, and effectively used their skills, knowledge and experience to support people and develop trusting relationships.

There were enough staff to support people and the permanent staff team were being supported by high agency staff hours whilst the provider continued to recruit to fill all vacancies. The senior management and registered manager needed to better understand what tasks staff did, to help ensure people continued to receive a prompt and effective service.

The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity, staff’s knowledge and people’s records ensured people received consistent support when they were involved in making more complex decisions, such as decisions around finances or where they wanted to live. Staff gained people’s consent before they provided car

This visit was carried out as a follow up visit to check on concerns in relation to care and welfare of people and staffing identified at the last inspection of this service in May 2014. We also looked at medication management during this visit as we had received some concerns about this.

We set compliance actions in relation to care and welfare and staffing. We received a report from the area manager that told us what they intended to do to achieve compliance.

We followed up on these areas of non compliance by undertaking an inspection on 23 September 2014.This inspection was completed by two inspectors over one day. During our visit we spoke with seven people who lived in the home and three visiting relatives. We also spoke with the area manager, acting deputy manager and the care staff on duty. We also looked at seven sets of care records for people and other records as appropriate. The evidence we collected helped us to answer the key question five key questions; is the service safe, effective, caring, responsive and well led?

We found that the areas of non compliance identified at the previous inspection with regards to care and welfare had been met but the service remained non compliant in staffing. We also found non compliance with medicines at this visit.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and staff told us.

If you want to see the evidence that supports our summary, please read the full report.

Is the service safe?

People and relatives we spoke with told us they were happy with the care and support they or their family member received. We were told, "I like it here, I'm well looked after" and " Mum's care is good, it's nice to be able to see things getting better."

We identified concerns around a lack of clear protocols for staff to follow for medicines prescribed on an 'as and when' basis and an inaccurate record of 'as and when' medicines in stock.

Is the service effective?

We saw care records for people had been reviewed and were being regularly evaluated following our visit in May 2014. We noted a couple of concerns with care plans and staff awareness in one suite which we raised with the area manager.

Is the service responsive?

People's medicines were generally managed safely for them. We found concerns with some people not being able to take their prescribed medicines when they wanted them. For example, we were told, "There is one medicine I take that I need to have early in the morning. I need to take it early in the day so that the effects wear off. If I don’t do this, it really affects the rest of my day and I can’t do the things I want to do. I have asked the staff to give me the medicine at 07.00 but it doesn’t always happen.”

The information we received from the provider regarding staffing levels in the home told us that the levels of staff were determined by a dependency tool used by the provider and were appropriate to meet the needs of the people. Our findings during this visit demonstrated that whilst some people felt there were enough staff to meet their needs, this was not always the experience for other people. For example people told us they had to wait for long periods of time when they required support or assistance. One person told us, "I have had to wait an unreasonable amount of time when I have called for staff to support me."

Is the service well led?

The area manager and acting deputy manager took on board to the concerns raised and assured us that they would follow up and investigate issues as necessary.

One inspector carried out the first day of this inspection. Following this visit we received some information of concern which related to people’s care and welfare. We therefore carried out a second visit as part of the inspection on 18 June 2014. The second visit was carried out by two inspectors. The focus of the inspection visits was to look at the concerns we had received and to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Shortly before our inspection another home in the local area owned by the provider closed for redevelopment. All of the residents and staff from this service moved as a group in to the extension that has just been built at The Lawns. This increased the number of people the Lawns could accommodate 35 from to 76.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, staff and carers told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. The records we read showed that the home was cleaned daily. We found the environment smart and tidy with no unpleasant odours. The people we spoke with told us they felt safe in the home. One of the people told us, “It has a nice, new look, it’s always clean.”

There were not enough staff on duty to meet the needs of the people living at the home and keep them safe.

There were arrangements in place to deal with foreseeable emergencies. This included 24 hours staffing, first aid training for staff, regular fire drills and a call alarm that people could use to call for assistance.

The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. The staff we spoke with had received DoLS training and understood their responsibilities in relation to this legislation.

Is the service effective?

Some people told us they were happy with the care they received and felt their identified needs were being met. One of the people we spoke with said, “They provide everything I need.” Other people were not satisfied with the care they received. One person told us, “We are very disappointed because we are not doing what we did at XXXX (previous merged service)”

We found that some of the care plans we looked at were not robust and reflective of people’s needs. We saw care plans were regularly updated, however this was not always reflective of people’s changing needs.

Is the service caring?

People were supported by kind and attentive staff. The staff we saw were caring when supporting people. The people we spoke with said, "The staff are great” and “The staff are very, very nice and good to you.”

Is the service responsive?

Where appropriate, the service shared information with other social and health care professionals. This ensured care was delivered to people safely when they transferred from other services.

People were asked what they liked to do by the service during needs assessments and the service acted in accordance with their requirements. People had been supported to pursue activities they enjoyed.

Is the service well-led?

The staff we spoke with were aware of the aims and objectives of the home and had a good understanding of the quality assurance processes that were in place. We saw people were regularly asked what they thought about the service and the manager took action to resolve any issues. People told us that the management had consulted with them before implementing changes to the service provided and their views had been taken into consideration. For example, changes were made to menus following discussions with people who used the service.

When we visited The Lawns we spoke with seven people who used the service and one visiting relative to obtain their views about the home. We also spoke with a visiting professional, the manager, the deputy manager, the area manager, three care staff, the chef and a member of the administration staff.

People who lived at the home told us, “I am happy here” and “The care staff are very good.”

We saw staff were kind and attentive when delivering care to people. We saw people were supported and encouraged to maintain their independence.

We looked at four people’s care records and saw their care plans reflected their personal needs. We saw the members of staff supported people as detailed within their care plans.

We saw that people were provided with a good choice of food and they told us they were happy with the choices available to them.

We spoke with two staff members about what they thought abuse was and they showed they had a good awareness of the importance of keeping people safe. They understood their responsibilities for reporting any concerns regarding potential abuse.

Care staff had received training to enable them to look after people safely and were given the opportunity to meet with the manager on a one to one basis.

We found the service was well led and had systems in place to monitor the quality of service being provided.

This inspection took place on 17 & 21 December 2015 and was unannounced.

The Lawns is a purpose built residential home which provides care to older people including some people who are living with dementia. The Lawns is registered to provide care for 76 people. At the time of our inspection there were 57 people living at the home.

At our last inspection in September 2014 we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We found there were insufficient staff to provide the care and support people required and we could not be sure people received their medicines as prescribed. The provider sent us an action plan telling us the improvements they were going to make. At this inspection we found some improvements had been made. The provider recognised further improvements were still required and were taking steps to ensure people received a quality service.

The service had not had a registered manager since October 2015. 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.

A registered manager from one of the provider’s other homes was temporarily managing this service. A new manager had been appointed and was due to take up their post in January 2016 and make an application to be registered with us.

Staff knew how to keep people safe from the risk of abuse. People told us they felt safe living at The Lawns and relatives we spoke with agreed their family members were safe. However, a staff member told us about a safeguarding incident that had not been referred to us or the appropriate authority. Following our inspection the provider notified the local authority and had commenced an investigation into the incident.

People, relatives and staff told us they felt at certain times in the day staff could not always support people in a timely manner. The deployment of staff required further improvements and closer management to ensure people’s needs were consistently met throughout the day.

Care plans were sufficiently detailed to support staff in delivering care in accordance with people’s preferences, although some required updating. There were occasions when delivery of care did not support people’s needs. For example, people were not always transferred safely by staff who had the knowledge and experience.

Staff received training in areas considered essential to meet people’s needs. The manager had identified staff required further training in areas specific to the needs of people living in the home. A programme of training had commenced to make sure staff continued to support people’s individual needs effectively.

People told us staff were respectful and kind towards them and relatives confirmed this. When staff provided support to people, they were caring and kind. Staff protected people’s privacy and dignity when providing care and asked people for their consent before care was given.

Staff understood they needed to respect people’s choices and decisions. Assessments had been made and reviewed to determine people’s capacity to make certain decisions. Where people did not have capacity, specific decisions were taken in ‘their best interest’. Relatives told us they were kept informed when certain care decisions were required and that their views were taken into account.

The provider was meeting the requirements set out in the Deprivation of Liberty Safeguards (DoLS). At the time of this inspection, five applications had been made under DoLS for people’s freedoms and liberties to be restricted. The manager had contacted the local authority and was in the process of reviewing people’s support to ensure people’s freedom was not unnecessarily restricted.

Family and friends were able to visit when they wished and staff encouraged relatives to maintain a role in providing care to their family members.

Some people we spoke with told us there were limited opportunities to promote their physical and mental wellbeing. Activities were available and provided to people living in the home, however it was recognised further improvements were required so staff had more time to spend talking with people. There had been no activities co-ordinator at the home for several weeks and the provider agreed this had impacted on the quality of social stimulation some people received.

People were supported to maintain their health and were referred to health professionals where appropriate.

The manager had identified and was improving processes and systems to make sure regular checks were completed to identify and improve the quality of service people received. The manager’s quality checks fed into an overall action plan to ensure improvements were made in the quality of service people received.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.