CQC report explained · a nursing home
What the CQC found at Cedar Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Medicines, risk assessments, recruitment, staffing checks and infection control were managed safely.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Good
- Inspectors found effective checks on quality, clear staff roles, good communication and an open approach to learning when things went wrong.
What inspectors found, May 2022
Cedar Court Care Home is rated Good; inspectors found safe care and effective management, but there was no registered manager in post.
This was an unannounced focused inspection on 30 March and 1 April 2022. Inspectors looked at Safe and Well-led because concerns had been raised about infection control, medicines, staffing and unlawful restraint.
The home was rated Good for Safe and Well-led. Inspectors found that medicines were managed safely, risks were assessed, staffing levels were safe on the inspection day, and infection control arrangements were suitable.
There was no registered manager in post. An experienced deputy manager was running the home with support from senior managers, while a new manager was waiting to start.
The ratings for Effective, Caring and Responsive were not inspected during this visit. The previous ratings for those areas were carried forward, so the overall rating remained Good.
Safe medicines systems
Medicines were ordered, stored, administered and checked safely. Extra signed checks had been introduced after earlier errors, and inspectors found no further errors after those checks began.
“We saw there were no other medication errors after those checks had been introduced.” from the report
Safe staffing on the visit
Inspectors saw enough staff to meet people's needs safely. Staff were busy but were not rushed and had time to speak with people.
“On the day of the inspection we observed that sufficient numbers of staff were dispatched to meet people's needs safely.” from the report
Good oversight
The home used regular audits, checks and handovers to monitor care and make improvements.
“The provider had quality assurance systems in place which were used effectively to monitor key aspects of the service.” from the report
Approachable management
People, relatives and staff generally spoke positively about the management. Staff said senior managers were available and listened to concerns.
“Staff told us the service was managed well and the deputy manager and the senior management team made themselves available to provide support if needed.” from the report
Some staffing delays
minorFeedback about staffing was mixed. One person said they sometimes had to wait for staff, and agency staff were often needed during a COVID-19 outbreak.
“However, one person told us, "If I ring a bell, I need to wait a little bit for staff. I think they might be short.” from the report
- 01Who is the registered manager now, and when did they start?
- 02How are staffing levels being managed when permanent staff are absent or agency staff are needed?
- 03What medication checks are now completed after each medicines round, and have there been any further errors?
- 04How are people and relatives told about any accidents, incidents or safeguarding concerns?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 6 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2021
Cedar Court Care Home was inspected but not rated; the targeted visit found safe medicines and systems for end-of-life care, while the previous overall rating remained Good.
This was an unannounced targeted inspection on 5 August 2021. Inspectors checked concerns about end-of-life care and medicines. They also looked at infection prevention and control.
Inspectors spoke with nine people, one relative and staff. They reviewed care records, medicines records, training information, accident and incident records, and quality checks.
The findings were positive. Medicines were managed safely, risk assessments were personalised, staff had training, and systems for end-of-life care were in place. The home was inspected but not rated because this was not a full inspection.
The previous overall rating was Good, published in March 2020. That rating remained unchanged. The CQC said it would continue monitoring information about the home until its next inspection.
Personalised risk planning
Risk assessments were completed for everyone and were regularly reviewed. They included detailed guidance about conditions such as diabetes, choking, epilepsy and mobility.
“Risk assessments were personalised and regularly reviewed.” from the report
Medicines managed safely
Medicines were received, stored, given and disposed of safely. Records matched the medicines administered, with no gaps or omissions found.
“There were no gaps or omissions in medication administration records (MAR).” from the report
Trained staff and health support
Staff completed induction and ongoing training, with competency checks. The home worked with health professionals and followed their advice.
“Staff received on-going training to ensure they had the correct skills and knowledge to support people safely and effectively.” from the report
Improving oversight
The provider used audits and incident analysis to improve the service. Inspectors found improvements in how quickly and fully accident and incident forms were completed.
“Quality assurance was used effectively and resulted in a significant improvement in the speed and standard of completion of accidents and incident forms.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including PPE, testing, admission arrangements and hygiene.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Inspectors raised no specific concerns in this report.
- 01How would you assess and record my relative's individual risks, and how often would you review them?
- 02How would you manage and record my relative's medicines, including any medicines given only when needed?
- 03How would you find out and record my relative's wishes about end-of-life care?
- 04What training and competency checks would staff caring for my relative have completed?
- 05How would you involve health professionals if my relative's needs changed?
This was a targeted inspection of specific concerns about end-of-life care, medicines and infection control; it did not review the full key questions, so all ratings were recorded as inspected but not rated and the previous overall Good rating carried over. This explanation was written from the published report of 1 September 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cedar Court Care Home
6 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015
Registered with the Care Quality Commission on 19 May 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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