CQC report explained · a residential care home
What the CQC found at Cedar Mews
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks were assessed, staffing was reviewed, medicines were managed safely after recent changes, and the home was clean with suitable infection control.
- Effective?
- Good
- People's health, nutrition and hydration needs were assessed and monitored. Staff had suitable training and worked with health professionals, although some mental capacity assessments needed more detail.
- Caring?
- Good
- The report does not give a new rating for Caring. Inspectors reported that people and relatives were positive about the friendly atmosphere, choice and involvement in daily life.
- Responsive?
- Good
- The report does not give a new rating for Responsive. People were involved in decisions about their care and activities, and their suggestions were recorded as acted upon.
- Well-led?
- Good
- The management team monitored quality, worked with other agencies and acted on medicine shortfalls. Staff described a positive culture, and people's and relatives' views were sought.
What inspectors found, November 2023
Cedar Mews is rated Good; inspectors found safe, effective and well-led care, with some improvements still being completed.
The inspection was unannounced and took place on 25 September 2023. Three inspectors and an Expert by Experience spoke with people living at the home, relatives, staff and a visiting professional. They reviewed care records, medicines records, staff files and quality records.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. Inspectors found that people were protected from abuse and avoidable harm, received suitable health and personal care, and were supported by a management team that monitored and improved the service.
There had been recent problems with some medicines, creams and dietary supplements not always being given as prescribed. The home had introduced an action plan and inspectors found improvements. Some mental capacity assessments also needed more detail, and the manager had agreed to improve them.
People felt safe
People told inspectors they felt safe and staff responded to requests for help. Risk assessments and emergency evacuation plans were in place.
“People told us they felt safe at Cedar Mews.” from the report
Choice and independence
People were involved in care planning and could choose when to get up, go to bed, eat meals and spend their day.
“People told us they made day to day decisions about their lives, choosing the time they got up and went to bed, where they ate their meals, and how they spent their day.” from the report
Food and health support
People's food and drink needs were met, with choices about meals and where to eat. Staff monitored health and worked with health professionals.
“People's nutritional and hydration needs were met.” from the report
Positive leadership
The management team worked with other agencies, listened to feedback and shared learning with staff. Staff described teamwork and an open culture.
“A proactive approach to seeking staff feedback and the provision of support, encouraged an open and inclusive culture for staff.” from the report
Medicine improvements were still recent
needs fixingAudits before the inspection found that prescribed creams and dietary supplements were not always given. Inspectors found improvements, but families should check how the action plan is kept under review.
“A recent quality and monitoring visit carried out by commissioners identified shortfalls in some aspects of medicine management.” from the report
Some capacity assessments lacked detail
needs fixingSome records did not fully explain how a person's mental capacity had been assessed. The manager had committed to improving the detail in future assessments.
“We found some assessments could be improved to provide greater detail to show how people's capacity had been determined.” from the report
- 01What changes were made after the medicine audits, and how do you check that creams and dietary supplements are now always given as prescribed?
- 02How will you make sure mental capacity assessments explain clearly how each decision about a person's care was reached?
- 03Which areas of care were not inspected during this visit, and what evidence can you provide about Caring and Responsive care?
- 04How are residents and relatives' suggestions about activities and daily care recorded and followed up?
- 05How do you involve relatives and health professionals when a person's health or capacity changes?
This was a focused inspection covering Safe, Effective and Well-led; Caring and Responsive were not given new ratings, and the report says ratings for key questions not inspected were carried over. This explanation was written from the published report of 4 November 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, November 2017
Rated Good; inspectors found safe, kind and well-managed care, with some care plans needing more individual detail.
This was an unannounced first comprehensive inspection on 5 October 2017. Inspectors spoke with people living in the home, staff, relatives and visiting health professionals. They observed care and checked care records, staff files, training records, staffing rotas, complaints and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitably trained staff, safe medicines practice, good safeguarding arrangements and care that respected people's choices, privacy and dignity.
People's needs were assessed and reviewed. They were supported with food, drink, activities and access to health professionals. The home had systems for dealing with complaints and checking the quality of care.
Inspectors said care plans contained enough information but would benefit from more detail to make them more individualised. A medicines audit had also found that some parts of medication records were not always completed, but this had been addressed.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs and saw that recruitment checks were completed before staff started work.
“People received their care and support from sufficient numbers of staff that had been appropriately recruited.” from the report
Kind and respectful care
Staff took time to listen, understand people's needs and support their choices. Inspectors saw people treated with dignity and patience.
“People had developed positive relationships with staff and were treated with compassion and respect.” from the report
Support for health and nutrition
People were helped to access healthcare and were supported to eat and drink enough. Staff understood individual dietary needs.
“People were supported to eat and drink sufficient amounts to maintain a balanced diet.” from the report
Activities and social contact
People could take part in activities such as baking, dancing, singing and trips out. The home had added weekend activity support after feedback.
“The service had a programme of activities and staff told us there was usually something going on for people to do.” from the report
Open management
People and staff described the management team as approachable. Audits and feedback were used to identify and address improvements.
“The provider had implemented a system of audits that were effective in assuring that any shortfalls in the service were identified and rectified in a timely manner.” from the report
Care plans needed more detail
needs fixingInspectors found the care plans adequate but said they needed more information to be more individualised and focused on each person.
“We found that although the care plans contained adequate information about people they would benefit from further detail to ensure they were more individualised and person centred.” from the report
Medication record completion
minorA medicines audit found that staff had not always completed the back of medication administration records. The report says this had been addressed, but families may wish to check that the improvement has continued.
“medicines audits had identified that staff were not consistently completing the back of medication administration record sheets (MARs) and this had been addressed.” from the report
- 01How will you make sure my relative's care plan includes enough individual detail about their routines, preferences and changing needs?
- 02How do you check that all medication administration records are completed correctly?
- 03What activities are available at weekends, and how will you support someone who does not want to join group activities?
- 04How will you respond if my relative's health or risks change?
- 05How can I raise a concern or complaint, and how will I be told what action was taken?
This was an unannounced first comprehensive inspection covering all five questions: Safe, Effective, Caring, Responsive and Well-led. This explanation was written from the published report of 22 November 2017 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 Mews
2 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017GoodSafe: GoodEffective: GoodWell-led: Good
- January 2017
Registered with the Care Quality Commission on 6 January 2017.
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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