CQC report explained · a residential care home
What the CQC found at Cedar Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Cedar Lodge is rated Requires Improvement; some safety and staffing improvements were found, but infection risks, building repairs and provider oversight remained inadequate, although special measures have ended.
This was an unannounced, targeted inspection on 1 August 2022. One inspector toured the home, observed care, spoke with two people, gathered information from the local authority and checked records about staffing, care plans, recruitment, audits and management oversight.
The home had improved since its previous inadequate rating. There were more staff, safeguarding arrangements were better, risk assessments had been updated and people had medicine profiles. However, inspectors found dirty equipment, damp and mould, stained and damaged surfaces, and an unsafe staircase that had not been altered as planned.
The provider's systems for checking quality and acting on problems were still ineffective. The home remained in breach of Regulations 12 and 17. It was no longer rated inadequate or in special measures, but the Requires Improvement rating means there was limited assurance about safety and management.
More staff
Inspectors found enough staff to meet people's needs, with care staffing much better than at the previous inspection.
“At this inspection visit there were enough staff available to meet people's needs.” from the report
Better safeguarding
The manager worked with the local authority safeguarding team, and staff knew how to recognise and report concerns.
“With the support of the guidance and support of the local authority there were systems in place to safeguard people at risk of abuse.” from the report
Improved medicines information
Each person had a medicines profile explaining their prescription and the support they needed to take medicines.
“This had been acted upon with each person having a medicine profile that told staff what medicines were prescribed and what support people required to take their medicines as required.” from the report
Some risks reduced
Thermostats had been fitted, wardrobes secured and unsafe items removed from shared bathroom cupboards. Care plans and risk assessments were also more informative.
“People were no longer at risk of scalding, as thermostats had been installed on hot water outlets identified at the last inspection.” from the report
Infection control
seriousInspectors found dirty commodes, toilet raisers and shower chairs, heavily stained flooring and no wash basin, soap or paper towels in the laundry. They said people remained at risk of cross-contamination and infection.
“This meant the risk of cross contamination remained and people were at risk of acquiring infections.” from the report
Unresolved fall risk
seriousThe main staircase still had low banisters. Although wood had been bought, it had not been installed and there was no firm date for the work.
“Therefore, people were still placed at risk of avoidable harm.” from the report
Weak provider oversight
seriousThe provider had not produced proper reports or action plans after visits. It also failed to identify or act promptly on some safety and infection control problems.
“The provider still did not have effective systems and processes in place to ensure they had a good oversight of the service.” from the report
Poor building condition
needs fixingDamp, mould, leaks, peeling paint, damaged flooring and worn bathroom fittings remained. Inspectors said these conditions could harbour bacteria and compromised people's dignity.
“These areas continued to pose a high risk of harbouring bacteria and potential illness to people.” from the report
- 01When will the low banisters on the main staircase be altered, and how are falls being prevented until then?
- 02What work will be done to remove the damp, mould, stained flooring and damaged bathroom surfaces?
- 03How will the laundry room be provided with proper handwashing facilities?
- 04What provider audits and written action plans are now in place, and how will you show that actions are completed on time?
- 05How do you check that cleaning of commodes, toilet raisers, shower chairs and bedding is completed consistently?
This was an unannounced targeted inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection. This explanation was written from the published report of 4 October 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, April 2022
Inadequate and placed in special measures; inspectors found serious risks from staffing, safeguarding, infection control and poor management.
This was an unannounced focused inspection on 15 and 21 March 2022. Inspectors spoke with people, a relative and staff, and checked care records, medicines records, staff files, rotas and management records.
They found people were at risk because staffing levels were sometimes too low, care and risk plans were missing, and safeguarding concerns were not always reported. The home was not consistently clean, some areas were in disrepair, and infection control arrangements were inadequate.
The home did not have effective checks to identify or correct these problems. Inspectors identified breaches of regulations covering safe care, staffing, safeguarding and management. The overall rating fell from Good at the previous inspection, published in 2019, to Inadequate.
The inspection covered Safe and Well-led only. The home was placed in special measures, meaning CQC said it would keep the service under review and normally re-inspect within six months.
People reported being happy
Despite the problems inspectors found, people told them they were very happy with the care they received.
“Despite the evidence found during this inspection, people told us they were very happy with the care they received.” from the report
Medicine stocks matched records
The check of medicine stocks against medication administration records found that they matched. Staff had also received medicines administration training, although competency checks were not always regular.
“An audit of medicine stocks against medication administration records [MAR] tallied.” from the report
Too few staff
seriousInspectors found occasions when only two staff were supporting 24 people. Some people needed two staff for personal care and moving around, leaving others unsupervised.
“There was insufficient staff available to meet people's needs and maintain effective cleanliness of the service.” from the report
Missing risk plans
seriousRisk plans were missing for needs including choking, diabetes, self-harm, pressure wounds and catheter care. One person had no care plan seven weeks after admission.
“There was a lack of risk management plans in place for people at risk of self harm, choking, acquiring infections, diabetes, pressure wounds and their catheter care.” from the report
Poor infection control and cleanliness
needs fixingInspectors found dirty commodes, stained or damaged flooring, limescale and missing hand-washing and protective equipment. There was no regular infection control audit.
“We found areas of the service unclean. Light pull cords throughout the service were found stained and in need of replacement.” from the report
Safeguarding failures
seriousPhysical and verbal incidents, including a person going missing, were not always reported to the safeguarding authority. Incident reviews were often incomplete.
“We raised a safeguarding referral following our inspection, where we identified incidents which had not been reported to safeguarding or the Care Quality Commission [CQC].” from the report
Weak management oversight
seriousManagement systems did not identify the problems found by inspectors. There were no effective quality audits or action plans for cleanliness, repairs and other improvements.
“The provider's governance systems in monitoring the quality and safety of the service were ineffective and did not identify the shortfalls we found at this inspection.” from the report
- 01What staffing levels are now in place on each shift, and how are people who need two staff supported?
- 02Which care and risk plans have been completed for choking, self-harm, diabetes, pressure wounds and catheter care?
- 03What infection control audits are now carried out, and how have cleaning, PPE, hand-washing equipment and damaged flooring been addressed?
- 04How are safeguarding incidents reported, reviewed and used to prevent similar incidents happening again?
- 05What action plan followed the inspection, and what evidence can you show of improvements since the home entered special measures?
This was an unannounced focused inspection of Safe and Well-led; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 April 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 Lodge
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- June 2019GoodSafe: GoodWell-led: Good
- August 2018
Registered with the Care Quality Commission on 9 August 2018.
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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