CQC report explained · a residential care home
What the CQC found at Cedar Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people's health, moving and handling, medicines and environmental risks were managed more safely. Infection control arrangements were also found to be suitable.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- The provider had improved its quality assurance systems, but some audits were mainly tick-box exercises. Problems such as unsafe water temperatures and outstanding bedroom repairs were not always identified or dealt with promptly.
What inspectors found, February 2023
Cedar Lodge Care Home is rated Good overall; inspectors found safe care, but leadership and quality checks still need improvement.
This was an unannounced, focused inspection on 31 January 2023. Inspectors checked Safe and Well-led, reviewed records and spoke with people, staff and managers. They also checked infection prevention and control.
The home had improved since the previous inspection. Risks about people's health, moving and handling, medicines, fire safety and the environment were better managed. Staff were trained, people said they felt safe, and there were enough staff to meet people's needs, despite a COVID-19 outbreak.
The overall rating is Good, up from Requires Improvement. However, Well-led remains Requires Improvement because audits did not always identify problems or make sure repairs and other actions were completed promptly. The previous breaches of Regulations 12 and 17 were no longer in place, but the new systems still need to become part of everyday practice.
Improved risk management
Care records identified specific risks and gave staff information about how to reduce them. Staff understood the risks affecting individual people.
“At this visit, we found the management of risks to people's health and well-being had improved.” from the report
Medicines safety
Staff were trained and assessed as competent. Protocols were in place for medicines given when needed, and records showed where patch medicines had been applied.
“At this visit, we found medicines were managed safely.” from the report
Staffing and recruitment
People and staff said there were enough staff, and people said call bells were answered quickly. Recruitment checks included references and DBS checks.
“People told us there were enough staff to support them.” from the report
People felt safe and listened to
People spoke positively about the support and said they felt safe. Most people who had raised concerns felt listened to and believed action was taken.
“People were pleased with the support and the quality of care they received.” from the report
Audits did not always spot problems
needs fixingSome checks were treated as tick-box exercises. Water temperature records included readings outside safe ranges, but these had been signed off as safe.
“We found some of these were more of a tick box exercise rather than driving the changes needed.” from the report
Repairs were not completed promptly
needs fixingBedroom checks had identified maintenance repairs in September 2022, but these were still outstanding when inspectors visited.
“People's bedroom checks identified some maintenance repairs were needed in September 2022, but these had not been completed.” from the report
Patch medicine advice was needed
minorPatch medicines were recorded and administered as prescribed, but the rotation of application sites was not always strictly in line with the manufacturer's guidance.
“However, this was not always strictly in line with manufacturer's guidance.” from the report
- 01How do you now check that water temperature readings are within safe ranges, and who reviews the results?
- 02Have all the maintenance repairs identified in September 2022 been completed?
- 03What advice did you obtain about rotating patch medicines, and how do you check staff follow it?
- 04How have the quality audits changed since January 2023, and how do you know they are finding and fixing problems?
- 05How will you keep families informed if there is another COVID-19 outbreak or visiting restriction?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 25 February 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, May 2022
Rated Requires Improvement; inspectors found kind and effective care, but ongoing safety and management failures left people at risk.
This was a focused inspection on 7 and 8 April 2022. Inspectors checked whether the home had acted on its previous improvement plan. They reviewed care, medicine and safety records, staff files and quality checks, and spoke with people, staff and professionals.
Some things were good. People said they felt safe, staff were available and care was unrushed. Inspectors found good support with food, health care, consent and staff training. The home was clean and infection control practices were generally good.
However, important problems remained. Fire doors and other environmental safety checks were not reliable. Medicine records and fridge temperature checks were incomplete. Checks by managers had not found these problems, and some risks in people's care records were not fully explained.
The overall rating stayed at Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective improved to Good. The home remained in breach of regulations about safe care and treatment and good governance.
Effective health support
People received support from health professionals when needed. Information was available to visiting professionals and staff followed their advice.
“People received health care services when they needed them. Referrals were made from the home to a variety of professionals, such as doctors, district and community nurses.” from the report
Good infection control
The home was clean and tidy. Inspectors were assured that personal protective equipment, testing and other infection control measures were being used effectively.
“The home was clean and tidy and good infection control practices were followed.” from the report
Fire and environmental safety
seriousSome fire doors did not close properly, and staff carrying out checks had not been trained enough to identify and fix risks. Other environmental checks also failed to find problems.
“Some fire doors did not close at all, while others closed at varying speeds.” from the report
Medicine records and storage
seriousRecords did not always show where pain patches had been applied. Two people lacked clear instructions for medicines given when needed, and fridge temperatures were not recorded every day.
“Not all medicine records lacked detailed information to confirm safe management, especially around pain patch medicine application and PRN protocols.” from the report
Weak management checks
seriousAudits and action plans had not reliably been completed or followed through. Managers had not identified several problems before the inspection.
“Several improvement actions we found during our visit had not been identified through any provider checks at the service.” from the report
Incomplete risk assessments
seriousSome people's risks, including smoking and catheter-related risks, were not fully recorded or explained to staff.
“Risks around people smoking or for people who had a catheter, risk assessments had not always been recorded or those specific risks considered.” from the report
CCTV and privacy
needs fixingCCTV in communal areas had been used without recorded consideration or consent, and there were no signs informing people and visitors. The manager switched it off during the inspection while its future use was considered.
“Regulatory requirements and considerations for CCTV were not considered before monitoring and recording took place.” from the report
- 01What has been done to ensure every fire door closes properly, and who now checks this and records the result?
- 02How are pain patch locations, as-needed medicine instructions and refrigerated medicine temperatures recorded and audited?
- 03What changes have been made to risk assessments for people who smoke or have catheters?
- 04What is the current position on CCTV, including consent, privacy checks and signs for people and visitors?
- 05What actions were included in the improvement plan sent to CQC, and what evidence can you show that they are complete?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the previous ratings for those questions were carried over. This explanation was written from the published report of 12 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.
Every inspection of Cedar Lodge Care Home
4 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015
Registered with the Care Quality Commission on 30 October 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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Worcestershire
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.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.