CQC report explained · a nursing home
What the CQC found at Cedar Falls Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always given in line with prescriptions, including medicines given covertly. Risks linked to distress and dementia, falls, infection control and the environment were not always managed effectively.
- Effective?
- Requires improvement
- Staff did not have all the training needed, particularly for dementia care. Mealtimes on the dementia floor were sometimes chaotic, and parts of the building needed repair and better signage.
- Caring?
- Requires improvement
- People's privacy, dignity and belongings were not always protected. Staff could be task-focused and did not always listen to people's views or involve relatives in care planning.
- Responsive?
- Requires improvement
- Activities and personalised support were not consistent, particularly for people living with dementia. The home did assess communication needs, investigated complaints and recorded people's end-of-life wishes.
- Well-led?
- Requires improvement
- Audits and other management systems had not identified important problems or driven improvement. Relatives did not always receive timely information, although people and staff were invited to meetings and staff said they felt able to raise concerns.
What inspectors found, December 2022
Cedar Falls Care Home was rated Requires Improvement; inspectors found risks in medicines, dementia care, dignity and management.
This was the first inspection of the newly registered service. It was unannounced and took place on 31 August 2022. Inspectors spoke with people living at the home, relatives, staff and managers. They reviewed care records, medicine records and management documents.
All five areas were rated Requires Improvement. Inspectors found that medicines were not always managed safely, infection control procedures were not always followed, and some risks for people living with dementia had not been properly assessed. Staff did not always provide personalised care, and people's privacy and dignity were not always respected.
There were also positive findings. There were enough staff overall, recruitment checks were completed, people's eating and drinking risks were assessed, and complaints were investigated. The provider took immediate action on some concerns and submitted an action plan. CQC said it would continue to monitor the home.
Staffing and recruitment
There were enough staff overall, and recruitment checks helped ensure staff were safe to work at the home.
“There were enough staff to meet people's needs and the provider had effective recruitment practices which ensured staff were safe to work at the home.” from the report
Eating and drinking safety
People's choking risks were assessed and diets or drinks were changed where needed. Weight was monitored and concerns were referred to the GP.
“People's ability to eat and drink safely were assessed. Where needed their diet was modified so their choking risk was minimised.” from the report
Complaints handling
Complaints were investigated under the provider's policy and reviewed for repeated themes that might lead to improvements.
“The registered manager had investigated complaints in line with the provider's policy.” from the report
Working with professionals
The home sought advice and support from health and social care professionals when people needed it.
“The provider worked collaboratively with health and social care professionals to ensure that people received care which met their needs.” from the report
Medicines and safety risks
seriousSome 'as required' medicines were given outside their instructions. Medicines hidden in food or drink were crushed without pharmacist approval, creating a safety concern.
“Protocols were not always followed by staff giving people medicines prescribed to people to be taken as required.” from the report
Dementia care and training
needs fixingStaff did not have enough dementia knowledge. Care could become task-focused, and there was not always guidance for responding safely when people became distressed.
“Staff lacked the knowledge of good dementia care and needed further training in this area.” from the report
Privacy and dignity
seriousPeople's rooms, belongings and personal dignity were not always protected. The report also described a person being left with wet trousers without support to maintain their dignity.
“People were allowed to wander into other people's rooms.” from the report
Management oversight
seriousAudits had not found or fixed serious concerns involving medicines, the environment, infection control and dementia care.
“The governance processes in the home had failed to identify the concerns we found.” from the report
Building and infection control
needs fixingSome furniture and toilet frames could not be cleaned effectively. There were also leaks, damaged flooring, poor decoration and limited signage for people living with dementia.
“Some equipment and furniture in the home was an infection control risk.” from the report
Mealtimes and activities
needs fixingThe experience was less positive on the dementia floor. Some people received cold food, food was mashed together, and activities were not used well to reduce distress and provide stimulation.
“On the first floor, where people needed more help, lunchtime was a more chaotic experience for people.” from the report
- 01What has changed to ensure 'as required' and covert medicines are now given safely and recorded correctly?
- 02What dementia training have staff completed, and how do staff respond when someone becomes distressed?
- 03How are people's privacy, belongings and dignity protected, especially in shared rooms and communal areas?
- 04What activities are now available for people living with dementia, and how are they tailored to individual interests?
- 05Which repairs and infection control improvements identified in the inspection have been completed?
This was an unannounced inspection covering all five key questions, including the premises and care provided; it was the first inspection of this newly registered service. This explanation was written from the published report of 16 December 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.
Every inspection of Cedar Falls Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Outstanding
- October 2019
Registered with the Care Quality Commission on 7 October 2019.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.