Our inspection took place on 7 February 2018 and 8 February 2018 and was unannounced.

Cherry Garden is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection.

Cherry Garden can accommodate 36 people across two floors, each of which has separate adapted facilities. The service cares for adults, including people living with early stages of dementia. The premises are a converted building with extensions. People live in their own bedrooms and have access to communal facilities such as a dining room, lounge and activities areas. Cherry Garden has a large garden at the side and rear of the building and is situated in a rural area. At the time of our inspection, there were 24 people living at the service.

The provider is required to have a registered manager as part of their conditions of registration. 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. At the time of our inspection, there was a registered manager in post.

At our last inspection on 18 January, 19 January 2017 and 20 January 2017, we found the provider had repeated breaches of Regulation 9, 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating was “requires improvement.” Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions effective, responsive and well-led to at least “good.” At this inspection, we found that the service had improved the process for obtaining people’s consent, that changes had occurred to ensure people received person-centred care, and better governance processes were in place to monitor the quality of care.

Improvements were made to staffing deployment, medicines management, infection prevention and control. This ensured people’s safety was maintained. This included protection from the risks of abuse, neglect, discrimination, injuries and accidents. The risks from the building and premises were mitigated, and people’s risk assessments ensured their care was safe. There were sufficient staff deployed to meet people’s needs. People were protected from the risk of infections. The service was clean and well-maintained. The management of people’s medicines was robust.

The service was compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were assisted to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practise. Better systems were in place for obtaining and recording people’s consent.

Staff training and supervision ensured employees had the necessary knowledge and skills to effectively perform their role. People’s care preferences, likes and dislikes were assessed, recorded and respected. We found there was appropriate access to community healthcare professionals to ensure people’s wellbeing. People had adequate nutrition and hydration. We made a recommendation about the redecoration and refurbishment of the premises.

Staff were described as caring and kind. There was complimentary feedback from most people who used the service and their families. People told us they were able to participate in care planning, if they wanted, but some people chose not to. People’s privacy and dignity was respected when care was provided to them.

The service had achieved person-centred care. There was increased information in care documentation about people’s specific likes, dislik

Cherry Garden is the only location the provider is currently registered for. The service provides nursing care for up to 36 people. Cherry Garden is situated in the village of Littlewick Green, close to the town of Maidenhead. It is set in large grounds surrounded by countryside. People who use the service live over two floors. There are 28 bedrooms, 2 lounges which look onto the gardens and a single dining room. The garden was designed to incorporate a sensory garden and wild life patio.

At the time of the inspection, there was no 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 2008 and associated Regulations about how the service is run. The deputy manager was acting in the role at the time of the inspection. We were made aware by the nominated individual that the role was offered to the staff member shortly before our inspection. After the inspection, the provider made us aware that the deputy manager had accepted appointment to the role. The deputy manager has commenced the registration process with us.

Our last inspection of the service was 26 July 2016, 28 July 2016 and 29 July 2016. This was an unannounced, comprehensive inspection. We gave the first rating to the service. We rated the service ‘requires improvement’ overall, but our key question ‘Is the service safe?’ was rated ‘inadequate’. We found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We served requirements against the provider and requested an action plan. This inspection was a further comprehensive inspection to determine what actions the provider had taken to ensure improved safety and quality of care.

The safety of people who used the service had increased. We saw that risks were better identified, understood, mitigated and documented. Improvements were made in specific areas since our last inspection. These included the decrease of risks like moving and handling of people, premises and the environment, medicines management and infection control. We made recommendations about medicines management and infection control. Some risks to people’s safety still required further improvement. This included safe staffing deployment as there continued to be use of inappropriate numbers of agency staff.

We found staff received appropriate support with induction, training and supervisions. Performance appraisals were not completed, but the management team were aware of this. Confusion regarding the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) codes of practice continued since our last inspection. We observed there was a focus to improve this by the home manager and the staff, but training in the area had not addressed the management of consent, mental capacity assessment and best interest decision making. The provider had invested in the premises to improve the physical environment for people who used the service. We made a recommendation about dementia-friendly refurbishment.

There was positive feedback from people and relatives we spoke with at Cherry Garden. They considered the staff were kind and caring. This was also reflected in written feedback the service received. We observed staff were more attentive to people’s needs and treated them with increased dignity and respect.

There was an increased effort to improve the personalisation of care documentation and people’s support. People’s likes, dislikes and preferences were recorded in addition to their life history. Further effort was required to ensure this was in place for all people who used the service. Activities coordinators offered a varied, engaging programme. The provider needed to examine people’s access to the local community for social purposes.

Significant changes in staffi

Cherry Garden is the only location the provider is currently registered for. The service provides nursing and residential care for up to 36 people. Cherry Garden is situated in the village of Littlewick Green, close to the town of Maidenhead. It is set in beautiful grounds surrounded by countryside. People who use the service live over two floors; the second floor accessed by a passenger lift. There are 28 bedrooms, two lounges which look onto the gardens and a single dining room. The extensive garden has been designed to incorporate a sensory garden and wild life patio.

At the time of the inspection, there was 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 2008 and associated Regulations about how the service is run.

Since registration under the Health and Social Care Act 2008 on 23 November 2010, Cherry Garden has experienced fluctuating compliance with the required regulations. Prior to this inspection, we had completed five inspections since the registration of the service under the Act. The most recent inspection was a desk-based review in September 2014, following outstanding non-compliance from a prior inspection on 5 June 2014. A desk-based review meant the inspector had assessed it was not necessary to perform a site visit, and instead reviewed documentation and other evidence sent by the provider. A full history of the service’s inspections and reports is available on our website. This is the first inspection and rating of the location under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were protected against abuse and neglect. However, we found people’s safety was at risk for other reasons. We found that moving and handling of people was dangerous and exposed them to the risk of an injury. A robust system of recruitment was required to ensure fit and proper staff provided care to people. Staffing deployment was unsatisfactory and we saw that staff were pressured and rushed. This meant people’s safe care was placed at risk. Maintenance of the premises was completed but major risks already identified were not acted upon by the provider. Infection prevention and control was below the required standard.

Staff did not receive effective training, support and appraisal. This meant they cared for people without the best knowledge and skills. The service had not complied with the Mental Capacity Act 2005. This was evidenced by a lack of staff understanding of mental capacity, best interest decision making and deprivation of liberty. People were provided with adequate nutrition and hydration. However at times people were placed at risk because the staff did not follow health professionals’ advice about how to change fluid consistency for people at risk of choking. We made a recommendation about staff training in malnutrition and thickening fluids. Refurbishment and redecoration of the service was required to make the premises more suitable and pleasant for people to reside in.

People told us staff were caring, although we did not always observe this during the inspection. Some staff demonstrated genuine kindness and compassion when assisting people. We observed other staff were focused on tasks and did not engage with the person they were caring for. There was a lack of people’s and relatives’ involvement in care planning and review. People’s privacy was protected, but not their dignity. Staff demonstrated inappropriate behaviour throughout the inspection which disrespected people that lived at Cherry Garden.

Risk assessments and care plans were in place for most people’s needs. Some risk assessments were missing for particular people and some care plans did not document the care in a personalised way. People did have the ability to voic

One adult social care inspector carried out this inspection. The purpose of the inspection was to check compliance against two regulations following two warning notices issued to the provider on 20 June 2014. These were for safety and suitability of premises and one for records. The focus of the inspection was to answer one of our five key questions; is the service safe? At this inspection we were following up enforcement action we had taken against the provider, we did not look at evidence to answer the other four key questions.

As part of this inspection we spoke with the operations manager and the handyperson. The registered manager was absent on the day of the inspection. We received information from the provider’s representative. We inspected the premises and looked at records related to people’s care. Although we checked people were safe, we did not speak to people at this inspection.

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

Is the service safe?

We observed people were happy in the communal lounges and dining rooms when we arrived.

We found the provider had taken steps to ensure safety of the premises. We saw this included; repairs of broken fittings completed by external contractors and the handyperson, compliance with the care home’s latest fire risk assessment recommendations and checks and repairs by a licensed gas fitter and electrician. People could have confidence that the provider was managing risks associated with the upkeep and maintenance of the building.

We found the provider had taken steps to ensure records were maintained and stored correctly. We saw nursing staff were required to review, update and where necessary archive people’s care documentation. Improvements had been made so files could be stored safely and documents destroyed securely. The provider had employed additional staff to assist care staff and the registered manager with record keeping.

Our finding was the provider had achieved compliance with the regulations following the two warning notices issued by the Care Quality Commission (CQC).

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with the four people who use the service, one visitor, the registered manager, the registered provider, five care staff and the handyperson. We also reviewed records relating to the management of the home which included risk assessments, audits and managerial reports, three care plans, daily care records and maintenance and premises documents.

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

Is the service safe?

People received safe care from the care workers and nursing staff. There were risk assessments and care plans in place which were individualised and identified how people should be best cared for. Monthly evaluations of people’s care documents were completed and other healthcare professionals were involved where this was required.

Since the last inspection on 13 September 2013, some improvements had been implemented to control risks presented by the premises and grounds. However, we found the safety of the premises and issues associated with it continued to present risks to people’s safety.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We found one application was recently submitted and that proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Since the last inspection, minor improvements had been achieved with regards to document management and storage. However, we found the provider continued to breach the requirements of this regulation.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed by staff. Our observations confirmed this. One visitor told us staff were: “Very good, very caring and with nice skills.”

Is the service responsive?

People’s needs had been assessed before they moved into the home. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff were clear about their roles and responsibilities. The registered manager and operations manager had oversight of the quality of care and the safety of people. There was a quality assurance system in place which identified, assessed and managed most risks to people, staff and others. The provider had not adequately managed some of the risks which had been escalated by the managers. The registered manager had commenced a course which assisted to develop their knowledge and skills in management of the regulated activities.

We used a number of different methods to help us understand the experiences of people who used the service because some people had complex needs and they were unable to tell us their experiences. Other people who used the service were able to tell us about their experiences but their feedback did not relate to the regulations we inspected.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We observed the end of breakfast, morning tea and also lunch. We saw people who needed assistance to have an adequate nutritional intake were provided satisfactory support during breakfast, morning tea and lunch.

People who use the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises. Whilst maintenance tasks had been completed, some risks identified by the home and other professional bodies had not been adequately addressed. In some parts of the home, the design and layout potentially placed people at risk.

Staff received appropriate professional development. We spoke with four care staff all of whom confirmed they attended and participated in regular training and supervision sessions.

People who use the service, their representatives and staff were asked for their views about their care and treatment and these were acted on. The registered manager facilitated ‘residents and relatives’ meetings every three to four months.

The provider was not always able to promptly locate records we requested. This was because the storage and management of records was unsatisfactory .

The registered manager had not commenced training necessary for the management of the regulated activities.

We spoke with two people who used the service. They told us they were well cared for. One person told us the staff were, "Lovely" and "I don't have anything to complain about". We observed the lunch service in the dining room and saw the cook was involved in serving people and talking to them about food. People were physically shown what was being served and were actively involved in choosing their meals.

Staff we spoke with told us they attended safeguarding training during induction and at regular intervals thereafter. This was confirmed against the training log the manager showed us. People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We spoke with two staff members who told us people were asked during care reviews if they had any concerns or complaints. The staff told us they would report all concerns or complaints to the manager. We saw how the manager investigated complaints and recorded them. People's concerns were used to improve the care provided in the home.