What the CQC found at Cedar Lodge (Nuneaton)

Inspectors were assured that the home had suitable measures for preventing and managing COVID-19 infection, including PPE, testing, social distancing and hygiene.

“We were assured that the provider was using PPE effectively and safely.” from the report

Medicine administration records showed that people received their daily medicines as prescribed. Nursing staff also had their medicine administration practice checked.

“We reviewed the medicine administration records which confirmed people received their daily medicines as prescribed.” from the report

The home completed references and criminal record checks for staff. Agency staff were checked before working in the home.

“The provider recruited staff safely through the requirement of references and application to the Disclosure and Barring Service (DBS).” from the report

People inspectors spoke with said they felt safe in the home and with staff.

“I feel safe in this place and with the staff.” from the report

Items that could be used for self-harm were accessible. Risk assessments did not always give staff enough information, and changes to observation levels did not have a clear process.

“The provider had failed to ensure people who were at risk of self-harm were kept safe.” from the report

Daily notes and incident reports were missing or incomplete. This meant staff might not know about current behaviours and risks or learn from incidents.

“A lack of detailed, up to date and accurate records meant there was a risk that all staff would fail to know of these behaviours, the resulting risks or how to mitigate against them to keep people safe.” from the report

Opening dates were missing from some liquid medicines, and tablet stocks were not counted after arrival. The home could not always confirm that medicines were safe to use or fully accounted for.

“We found the date when medicines were opened had not always been recorded for all liquid medications which meant the provider could not be confident those medications were safe to use.” from the report

Quality systems did not identify important gaps in risk assessments, records, medicines management and incident reporting. Children and adults shared space without suitable systems to assess the related risks.

“The lack of governance systems and oversight meant people were at risk of receiving poor quality care.” from the report

Relatives and professionals reported poor communication. Some people were not receiving planned therapy or care-plan sessions.

“Family members we spoke with told us the home did not involve them and communication with them was poor.” from the report

The home relied on a high number of agency staff. People told inspectors that some agency staff did not know them well enough or understand their needs.

“Sometimes they have too many agency staff and they don't respect you and don't want to get to know you.” from the report