A comprehensive inspection visit took place on 19 September 2018 which was unannounced. We returned announced on 21 September 2018 so we could review the provider’s quality assurance systems and to speak with more staff about what it was like to care for people living at Cherry Trees.

Cherry Trees is a nursing home, which provides care for up to 81 people in three units, located across two floors. At the time of our inspection there were 68 people living at Cherry Trees. The nursing unit was on the ground floor called ‘Young at Heart’ and residential and respite care was provided on the first floor in ‘Cherry Blossom.’ People living with dementia were also supported on the first floor referred to as ‘Memory Lane’. People had their own bedroom and all the bedrooms had en-suite facilities, plus people had the use of shared communal lounges, a dining room and bathrooms.

People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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 a registered manager in post.

At our last comprehensive inspection in September 2017, we rated the service ‘Requires Improvement’ overall. We found the provider was in breach of two regulations of the Health and Social Care Act 2008 because insufficient staffing levels had a negative impact in how people received person centred care.

At this inspection we found improvements had been made and the overall rating had changed to ‘Good’. The provider had increased staffing levels at the home and people’s care and support needs were met, but better deployment of staff was needed at times, especially when shifts remained below the provider’s own assessed levels of staffing. We found the provider was no longer in breach of the regulations. However, the challenges of the environment meant some relatives shared continued concerns that staff were not always visible and ‘on hand’ to offer assistance to their family member when needed. The registered manager said they would consider how they communicated with relatives to assure them there were sufficient numbers of staff on duty to meet needs.

Staff protected people from risks of abuse. All staff understood what actions they needed to take if they had any concerns for people's wellbeing or safety. Staff felt confident to raise concerns with the senior staff, the registered manager and provider.

Staff received refresher training to continue to keep their skills, knowledge and practice updated. People’s care and support was provided by a caring and more consistent staff team, because the provider’s reliance on agency staff had reduced since the last inspection. Staff said reducing agency staff had improved communication and improved care delivery.

Staff worked within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff recognised the importance of seeking people’s permission before care was provided. Where people’s liberties were restricted, necessary approvals had been requested.

Staff were caring in their approach and interactions with people. The investment in keeping the environment safe and risk free showed the provider had considered how their actions impacted on those in their care.

The provider’s research and evaluation into their own dementia programme was to enhance the wellbeing of people living with dementia, especially those people living in ‘Memory Lane’. Th

The inspection took place on 6 September 2017 which was unannounced and we agreed to return on 8 September 2017 so we could speak with staff and to look at the governance systems and audits.

Cherry Trees is a nursing home which provides accommodation and personal care to older people living with dementia, young adults and people with physical disabilities. Cherry Trees is registered to provide care for up to 81 people. At the time of our inspection visit there were 61people living at the home. The home provides nursing care across two floors. On the ground floor were people with physical disabilities and people living with dementia. On the first floor, referred to as ‘Memory Lane’, staff supported people living with dementia.

There was no registered manager in post. The registered manager left the service in April 2017. 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. The provider had ensured the home was supported by an ‘interim’ manager from within the organisation in the absence of a registered manager. The new manager who is referred to throughout this report as the “manager” had been in post since July 2017. The manager was in the processing of registering with us.

Cherry Trees was last inspected in April 2016 and was rated as ‘Good’. Prior to this inspection we received information that staffing levels did not always meet people’s needs. At this inspection, we found staffing levels impacted on the quality of care and service people received.

Staffing levels were unsafe because there were not enough of them to support people in line with their preferred choices and assessed needs. Some staff told us they enjoyed working at the home, however low staff numbers affected their morale because the service they provided was not to the standard they wanted. Before our second inspection visit, we received written confirmation from a senior regional director that staffing levels were increased by one staff member to support people living on ‘Memory Lane’. When we returned on 8 September 2017, staff said this had already made a positive difference and they were able to monitor people more responsively and not rush.

People living at Cherry Trees told us they felt safe. Care staff understood their responsibilities in being observant at all times to keep people safe. However, there were periods of time when communal lounges and areas of the home were not occupied because staff needed to support people elsewhere in the home. This placed some people at increased risk of not receiving support and assistance when required. We found information related to risks associated with people’s care was not always clearly recorded or consistently managed.

Staff knew how to recognise abuse or poor practice and told us they would report abuse if they observed this happening. We found that not all reportable incidents related to people’s health and safety had been reported to us.

Staff had been supported with training to help ensure they understood how people who lacked capacity could be supported to make decisions. Staff knew they could not undertake care practices against the wishes of people in the home. The management team had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People had been assessed to determine how decisions could be made in their best interests and applications for DoLS had been completed. Authorisations that had expired had been reapplied for.

People and our observations showed staff were mostly caring in their approach and people told us staff were kind and considerate. When staff were available in the communal areas, it was more reactive support rather than ident

This inspection took place on 21 and 22 April 2016 and was unannounced.

Cherry Trees is a nursing home which provides care to older people living with dementia, young adults and people with physical disabilities. Cherry Trees is registered to provide care for up to 81 people. At the time of our inspection there were 55 people living at the home. The home provides nursing and care support across two floors. On the ground floor were younger people with physical disabilities and older people. On the first floor, referred to as ‘Memory Lane’, staff supported people living with dementia.

There was no registered manager in post. The registered manager left the service in January 2016. 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. The home was being managed by a manager but had not yet submitted their application to become registered with us.

Staff knew how to keep people safe from the risk of abuse. People told us they felt safe living at Cherry Trees and relatives agreed their family members felt safe and protected from abuse or poor practice.

The provider assessed risks to people’s health and welfare and wrote care plans that minimised the identified risks. However, some care records and risk assessments required updating to make sure staff provided consistent support that met people’s needs.

There were enough staff on duty to meet people’s health needs. The manager had recently reviewed people’s needs and increased nursing support on both floors. The manager continued to reassess staffing levels to ensure people living at the home, continued to receive a responsive and effective service. The premises were regularly checked to ensure risks to people’s safety were minimised.

People’s medicines were managed, stored and administered safely in line with GP and pharmacist prescription instructions.

People were cared for by kind and compassionate staff, who knew their individual preferences for care and their likes and dislikes. Staff understood people’s needs and abilities and they received updated information at shift handovers to ensure the care they provided, supported people’s needs. Staff training had improved and staff felt they had the right skills and knowledge to support people safely and effectively.

Nursing staff and care staff supported and promoted people’s choice, but they had limited understanding of mental capacity and their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Records showed consideration had been made if a persons’ liberty may be deprived, as the provider had made applications to the local authority.

People were offered meals that were suitable for their individual dietary needs and met their preferences. People were supported to eat and drink according to their needs, which minimised risks of malnutrition. Staff ensured people obtained advice and support from other health professionals to maintain and improve their health, and when their health needs changed.

People and their representatives felt recent changes at the home were for the better and people received care from a more consistent staff team. People benefitted from this because staff knew people well and were responsive to their individual needs.

Care was planned to meet people’s individual needs and abilities and care plans were reviewed although some information required updating to ensure staff had the necessary information to support people as their needs changed. People were supported to pursue their interests and hobbies and live their lives how they wished, and staff supported people to remain as independent as possible.

The quality monitoring syste

At our previous inspection in May 2014 we found the service needed to make improvements in infection control procedures, supporting staff and suitability of equipment. We inspected the service to follow up on these issues and to check that the service had made the necessary improvements. At this inspection we found improvements had been made.

Sixty two people who required personal or nursing care were living at Cherry Trees at the time of our visit. The home was divided into three sections. On the ground floor younger people with physical disabilities were located alongside a unit called 'young at heart' where older people lived. On the first floor of Cherry Trees we saw older people with dementia were cared for in a unit called 'memory lane'. During our inspection we spoke with people from all the units at Cherry Trees.

Some people were unable to communicate with us verbally. We spent time in the communal areas of the home observing people to see how they spent their time, and how staff interacted with them.

We spoke with 11 people who lived at Cherry Trees about their experiences of the service. We also spoke with eight relatives about their family member's experience. We observed the care that was given to people during our inspection. We looked at care records at the home.

We spoke with a range of staff including six members of staff who provided personal care or nursing care to people at Cherry Trees, housekeeping staff, kitchen staff, the deputy manager, the manager, and the regional operations director of the service.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff who supported them and from looking at records. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

Staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the steps to take if they were concerned that abuse had taken place.

Safeguarding procedures were robust. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs). No recent applications had been submitted to deprive anyone of their liberty. Relevant staff were trained to understand when an application should be made and how to submit one. The manager was aware of the latest guidance and information on DoLs.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistle-blowing and investigations. This reduced the risks to people and helped the service to improve.

We looked around the home during our inspection to check the home was clean. We looked at the procedures in place to protect people from the risk of infection. We found people were cared for in a clean, hygienic environment.

Is the service effective?

People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate.

People had access to a range of health care professionals, some of which visited the home.

It was clear from our observations and from speaking with staff they had a good understanding of people's care and support needs and that they knew them well.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.

People and relatives we spoke with were positive about the care provided by staff. One person who used the service told us, “What a lovely peaceful home this is, I really do like living here. Staff treat me in a respectful and kind way, with dignity and they respect what I say and listen to what I’m saying."

Is the service responsive?

We saw people were able to access help and support from other health and social care professionals when necessary.

People were able to participate in a range of activities both in the home and in the local community.

People who used the service, their relatives and other professionals involved with the service completed satisfaction surveys. Where shortfalls or concerns were raised these were analysed and addressed.

We looked at how complaints had been dealt with by the service. We found that complaints were investigated and dealt with in a timely way.

Is the service well-led?

Following our previous inspection of the service in May 2014, we asked the provider to make a number of improvements. At this inspection we found that actions to improve the service had been taken.

The service had a quality assurance system in place to identify areas of improvement.

We found staff were appropriately supported and supervised. We found staff employed to work at the home had the necessary skills needed to support the people who lived there.

People's personal care records were up to date and complete.

We had previously received some information of concern from staff and people using the service. We were informed that the home had temporarily stopped admitting new people into the service. The home is currently accommodating 68 people.

We spoke with staff, people using the service and their relatives. People told us that there was poor staff morale, staff felt unsupported and staffing levels were insufficient to meet people's needs. A comment made by one person we spoke with was, ‘’Staff seem very busy and when we need them they don’t come straight away.’’ We were told that this had impacted on people's care and support.

We saw that systems to supervise and appraise staff performance had not taken place. The staff training log showed shortfalls in staff training and staff told us that specialist training such as supporting people with challenging behaviour was not available. We were told of a lack of staff induction and mentorship for new staff.

We reviewed people’s care records and found that some records did not reflect all aspects of their care. We saw evidence of incomplete records. This could put the person or staff member at risk as all of their needs and support had not been identified. We observed that monitoring of the service had not been robust.

We looked at medicines management across the home and found that it was not safe in a number of areas. The majority of our concerns related to the Oversley Wood unit.

We visited this service in August 2011 and assessed the quality of care provision. We found the service were not fully compliant with the required regulations and issued five compliance actions for the service to address. These actions related to: involving people more in their care, delivering care as identified in their care records, protecting people from potential abuse, addressing the negative outcomes for people resulting from ineffective staffing arrangements and ensuring systems for monitoring quality were effective.

Cherry Trees provides care for young physically disabled people, people with dementia and the frail elderly. During this visit we were assisted by two 'experts by experience' to visit all three units. These are people who have personal experience of using services such as this one or who have cared for someone who uses this type of care service.

We found improvements across all areas but found continued concerns in relation to involving people in their care/respecting people’s choices and with staffing arrangements.

Many people at Cherry Trees had health conditions which restricted their ability to communicate or make choices about their care. We therefore relied on observation and discussions with visitors to obtain views about the service. It was not clear that people with limited communication were being involved in their care as much as they should. The expert by experience who observed the young physically disabled people told us: “A number of people did not communicate verbally and staff did not appear to know how some people communicated saying that they did not communicate”. We saw that records did not clearly indicate communication methods.

Social activities were being provided and additional staff had made available to enable people to better access to these. Some people indicated that they were not aware the activities were taking place. One person in the young physically disabled unit said there were “bad days” referring to lack of social activities provided for them.

People felt that their care needs were being met and this had been helped by the addition of a new general manager working in the home. They told us: “I think X has been wonderful” (new general manager). One person told us about their care plan they stated: “…they have just reviewed it. I like to go for a walk….it is in my care plan”. Others explained to us how staff supported them with personal care and told us staff were “fine”.

We found that actions had been taken to ensure people were better protected from any potential abuse. Staff told us: “Since X started as manager there have been much improvements, she works in a professional way and sorts out problems”. The expert by experience who witnessed a potential challenging behaviour incident between two people in the dementia unit, they told us: “The carer quickly defused the situation by suggesting the lady went with her and I continued to talk to the man”.

Whilst we received positive comments about staff themselves it was evident that at certain times of day staffing arrangements were not effective. People told us: “The staff are very good”. “There are sometimes no staff in the lounges for what seems to be quite long periods of time”. We saw that some people were not experiencing a positive mealtime experience. Some people were still eating lunch close to 3pm.

Since our last visit improvements had been made on monitoring the quality of care and services. Audits of care records had been carried out to make sure they accurately reflected people’s needs. Meetings had taken place with people and relatives across the three units. Areas for improvement had been discussed and action plans were in the process of being devised and implemented.

A number of people at Cherry Trees have a dementia diagnosis and were unable to offer a view on how their preferences were sought. We made observations of their care and reviewed information held in their records.

We found that people in the Frail Elderly (FE) and Young Physically Disabled (YPD) units were being given choices about their care provision in some areas but not others. Some of their preferences and choices regarding their care were evidenced through signatures of agreement in their care files. People in the YPD unit told us that their choices of social activities were limited. They told us that people who were dependant on staff to provide social activities would be “bored”. Comments included :“I have never played ‘Bingo’ and would rather play ‘Bridge’ but I haven’t been asked what I would like to do”. Relative meeting notes seen indicated that they felt some of the care plans for their relative were not representative of their needs and choices.

We saw that people in the dementia unit had regular access to social activities within the home. An outside entertainer was providing music entertainment in the dementia lounge on the day of our visit.

Some people spoken to told us they were happy with their care and that staff were kind but commented “we need more staff” and told us staff appeared “rushed” sometimes although they were “willing and able” and respectful when providing care.

Relative meeting notes seen included the comments: “The staff are second to none, helpful and so caring”. “Impressed by the unit manager and his team”. “Staff very tired and working lots of extra shifts to cover home. Staff very busy and some residents are being assisted to get up very late in the morning”. “Too few pairs of hands”. “Laughter has gone”. “Some staff seem to lack motivation at times due to workload, relatives concerned for staff and residents”. Other comments in the notes included: “Food reported to be generally good”. “Injuries/falls/ incidents are reported to relatives promptly now”.

People on the ground floor told us about having to wait for long periods of up to “half an hour” for staff to respond to call bells because the system was not compatible with the new environment.

We inspected the service over a two day period, during which a pharmacy inspector, an expert by experience and two inspectors reviewed information at Cherry Trees. We also checked on concerns that had been raised at our inspection in September 2013 to see whether improvements had been made. We found that improvements had been made, but further improvements were still required in some areas.

Sixty eight people who required personal or nursing care were living there at the time of our visits. The home was divided into three sections. On the ground floor younger people with physical disabilities were located alongside a unit called 'young at heart' where older people lived. On the first floor of Cherry Trees we saw older people with dementia were cared for in a unit called 'memory lane'. During our inspection we spoke with people from all the units at Cherry Trees.

Some people were unable to communicate with us verbally. We spent time in the communal areas of the home observing people to see how they spent their time, and how staff interacted with them.

We spoke with 11 people who lived at Cherry Trees about their experiences of the service. We also spoke with six relatives about their family member's experience. We observed the care that was given to people during our inspection. We looked at care records at the home.

We spoke with a range of staff including seven members of staff who provided personal care or nursing care to people at Cherry Trees, the deputy manager, the acting manager, and the regional operations director of the service.

The registered manager shown at the top of this report had left their role at the time of our visit. The acting manager has been in place for six weeks and was in the process of becoming the registered manager of the service. We refer to the acting manager in this report as the manager.

During our inspection we looked to see whether we could answer five key questions: Is the service safe, effective, caring, responsive and well led? Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the steps to take if they were concerned that abuse had taken place.

We found staff could raise issues of concern with the service. They were told about the whistle-blowing policy and procedures when they started working at the home. The whistle-blowing procedure ensured staff were protected during any subsequent investigation.

Safeguarding procedures were robust. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs). No recent applications had been submitted to deprive anyone of their liberty. Relevant staff were trained to understand when an application should be made and how to submit one. The manager was aware of the latest guidance and information on DOLs and was planning a review of their procedures to ascertain whether any changes were required to the policy.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistle-blowing and investigations. This reduced the risks to people and helped the service to improve.

We checked whether people's medicines were being managed safely. We found people's medication was being appropriately administered and safely managed.

We looked around the home during our inspection to check the home was clean. We looked at the procedures in place to protect people from the risk of infection. We found people were not always cared for in a clean, hygienic environment. We have asked the provider to send us an action plan stating how they will improve in this area.

Recruitment procedures were rigorous and thorough.

Is the service effective?

People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate.

People had access to a range of health care professionals, some of which visited the home.

It was clear from our observations and from speaking with staff they had a good understanding of people's care and support needs and that they knew them well.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.

People and relatives we spoke with were positive about the care provided by staff. One person who used the service told us, “The staff are all lovely”.

Is the service responsive?

We saw people were able to access help and support from other health and social care professionals when necessary.

People were able to participate in a range of activities both in the home and in the local community.

People who used the service, their relatives and other professionals involved with the service completed satisfaction surveys. Where shortfalls or concerns were raised these were analysed and addressed.

We looked at how complaints had been dealt with at the service. We found that complaints were investigated and dealt with in a timely way.

Is the service well-led?

We reviewed the service at a previous inspection in September 2013, where we told the provider they must make a number of improvements. At this inspection we found that some actions remained outstanding. We were concerned that the service had not effectively monitored the completion of the action plan.

The service had a quality assurance system in place to identify areas of improvement.

We found staff were not always appropriately supported and supervised. We found staff employed to work at the home did not have all the necessary skills needed to support the people who lived there. We found staff were not offered regular yearly appraisals to monitor performance and identify training and development opportunities. We have asked the provider to send us an action plan stating how they will improve in this area.

People's personal care records were up to date and complete.