CQC report explained · a nursing home
What the CQC found at Cedar Court Nursing Home (Dementia Unit)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Requires Improvement; inspectors found kind, responsive care but gaps in records, risk checks and leadership systems.
This was an unannounced comprehensive inspection on 9 June 2023. Two inspectors and an Expert by Experience observed care, spoke with people and staff, and reviewed eight care records and several medicine records.
The home was rated Good for Effective, Caring and Responsive. Inspectors found staff were kind, respected privacy, supported people's choices and helped people keep in touch with family and friends. Medicines were given as prescribed, staffing levels were considered suitable, and people were supported to access health professionals.
The home was rated Requires Improvement for Safe and Well-led. Some risk information and care records were incomplete or inaccurate. Quality checks had not found these problems, some staff were unclear about the restraint policy, and exposed hot pipes created a scalding risk. Lunch delays were also seen, although staggered mealtimes were introduced immediately.
The overall rating changed from Good at the previous inspection to Requires Improvement. The provider breached Regulation 17 on good governance and was required to send an action plan.
Kind and respectful care
Inspectors observed staff treating people kindly and respecting their dignity and privacy. People were involved in decisions about their care whenever possible.
“Staff maintained people's dignity and respected their privacy.” from the report
Medicines managed safely
People received their medicines as prescribed. Records were accurate and medicines were stored and disposed of safely.
“People received their medicines as prescribed. Staff managed medicines consistently and safely.” from the report
Suitable staffing and training
Inspectors found staffing levels matched the dependency tool and staff were able to meet people's needs. Recruitment checks, induction and training were in place.
“People, their relatives and staff told us there was enough staff to meet people's needs” from the report
Personalised support
People's preferences, backgrounds, communication needs and choices were recorded and understood by staff. People were supported to maintain relationships and take part in activities.
“People and their families were involved in developing their care, support and treatment plans whenever possible.” from the report
Incomplete care records
needs fixingSome care plans and daily notes were not complete, consistent or accurate. This created a risk that important details about people's care could be missed.
“Some records associated with people's care had missing entries and inaccurate daily notes.” from the report
Weak quality checks
seriousThe provider's audits did not consistently identify problems with care records, safety risks or staff knowledge of key policies. This led to a breach of Regulation 17.
“The provider had failed to implement effective systems and processes to assess, monitor and improve the safety of the service provided.” from the report
Exposed hot pipes
seriousMultiple hot radiator pipes were not covered and could have caused scalding. The provider dealt with this on the day of the inspection.
“We identified multiple hot radiator pipes which were not covered putting people at risk of scalding.” from the report
Unclear restraint policy
needs fixingSome staff did not clearly understand the home's restraint policy. Inspectors were told agency staff might not know key policies, increasing the risk of inconsistent responses to distressed behaviour.
“Some of the staff we spoke to did not demonstrate clear understanding of home's Restraint Policy.” from the report
Delays at lunchtime
needs fixingInspectors saw a chaotic lunchtime, with some people waiting a long time for food and becoming frustrated. The manager introduced staggered mealtimes immediately.
“We saw some people got frustrated due to the delay.” from the report
- 01What daily checks are now used to make sure care records accurately show risks, nutrition, fluids and care delivered?
- 02How are you checking that all permanent and agency staff understand the restraint policy and other key policies?
- 03What action was taken to cover all hot radiator pipes, and how are environmental risks now identified?
- 04How have staggered mealtimes changed waiting times, and how do you record food and fluid intake?
- 05What progress has been made on the action plan required after the Regulation 17 breach?
This was an unannounced comprehensive inspection covering all five key questions, including infection prevention and control. This explanation was written from the published report of 20 July 2023 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, January 2021
Cedar Court Nursing Home (Dementia Unit) was rated Good; inspectors found safe, kind care and stronger management, but nursing recruitment and some medicines records needed attention.
This was an unannounced focused inspection on 9 December 2020. Inspectors looked only at Safe and Well-led because concerns had been raised about infection control, staffing and risk management. They spoke with people living in the home and eight staff members, observed care, checked records and reviewed further documents after the visit.
The home was rated Good for Safe and Good for Well-led. Inspectors found enough staff to meet people's needs, effective infection control, safe medicines systems and good management of risks. They also found kind, patient care and good communication with relatives.
The overall rating improved from Requires Improvement at the previous inspection. However, the inspection did not reassess Effective, Caring or Responsive. Those ratings were carried forward from earlier inspections.
Medicines managed safely
People received their medicines as prescribed. Staff had guidance for medicines given when needed, including where people could not explain pain or distress.
“People received their medicines as prescribed and the risks associated with medicines were managed effectively.” from the report
Infection control
The home used regular cleaning, staff PPE training, testing and isolation arrangements. It also created a visiting pod and staff changing room during the pandemic.
“Infection control measures were in place across the home.” from the report
Managing risks
Staff assessed and reviewed risks such as falls, poor nutrition, distressed behaviour and sore skin. Inspectors saw staff using calm, personalised approaches to support people.
“Risks to people's health and wellbeing were assessed, actions put in place to reduce the risk and this was regularly reviewed.” from the report
Kind and personal care
Inspectors observed kind and patient care. Care plans included people's life histories and helped staff provide personal support.
“Care plans were detailed and clear; they guided staff to provide person centred care by describing the person's whole life and history.” from the report
Family communication
The home used video calls, photographs and a visiting pod to help families stay connected when normal visiting was restricted.
“The staff organised a video call on their birthday so we could see them opening presents.” from the report
Medicines records
needs fixingThere were gaps in recording medicines administration for two previous days. The issue had been reported and investigated, and inspectors were told that no harm had occurred.
“We saw that there were some gaps in recording of administration for two previous days.” from the report
Nurse recruitment
needs fixingThe home was recruiting nurses and used agency nurses in the meantime. Regular agency nurses and close supervision were being used as safeguards.
“The provider was actively recruiting nurses to join the staff team.” from the report
Registered manager
minorThe home did not have a manager registered with the CQC at the time of the inspection. A manager was applying to register.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01Have the nursing vacancies now been filled, and how often are agency nurses still used?
- 02What checks are now in place to make sure every medicines administration is recorded correctly?
- 03What is the current position on the manager's CQC registration?
- 04How will you support visits, video calls and regular updates for families if restrictions return?
- 05How are my relative's personal history, risks and changing needs recorded and shared with staff?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 1 January 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 Nursing Home (Dementia Unit)
8 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Cedar Court Nursing Home (Dementia Unit) →
- January 2021Goodup from Requires improvementSafe: GoodWell-led: Good
Read what inspectors found at Cedar Court Nursing Home (Dementia Unit) →
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2018Inadequatedown from Requires improvementSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2017Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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