Updated 24 November 2020
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was completed by an inspector, an inspection manager and a member of the CQC medicines inspection team working on-site and two assistant inspectors working off-site. The CQC medicines team is made up of a mixture of pharmacists and pharmacy technicians. The assistant inspectors spoke with staff by telephone. An Expert by Experience spoke with people’s relatives off-site. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Cherry Blossom Manor is a ‘care home’. People in care homes receive accommodation and nursing 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.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced. We contacted the service prior to entry to ensure there was no-one isolating with confirmed or suspected Covid-19 and to ensure the inspectors complied with the service’s policy on the use of personal protective equipment.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.
During the inspection
We spoke with eight people who used the service and seven relatives about their experience of the care provided. We spoke with 21 members of day and night staff, including care staff, nurses, the registered manager and members of the provider’s senior management team. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. These included eight people’s care records, 15 medicine administration records and 14 medicines related care plans. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. A further four relatives and thirteen staff contacted CQC to provide their written feedback on the service. We also spoke with a professional who regularly visits the service.