CQC report explained · a nursing home
What the CQC found at Cedar Tree Care Home Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured about the home's infection prevention and control arrangements.
Inspectors visited the home on 29 January 2021. This was an announced, targeted inspection because of coronavirus outbreaks in care homes. They looked only at infection prevention and control.
Inspectors were assured that the home was managing infection risks. This included visitor restrictions, isolation, social distancing, personal protective equipment, testing, cleaning and the layout of the building. Staff also received extra infection control training.
The home kept people in contact with relatives through video and phone calls when visits were stopped. Inspectors did not give an overall rating or rate the other areas of care, so this report is not a full assessment of the home.
Infection controls
The home used isolation, social distancing, separate staff areas and room 'bubbles' to reduce the risk of infection spreading.
“The building was designed so rooms were in bubbles of four and staff were allocated to these bubbles to reduce the risk of cross infection.” from the report
Testing and monitoring
Staff were tested regularly, and people's temperatures and oxygen levels were checked twice a day to identify changes quickly.
“The registered manager had set up a COVID-19 testing room with bathroom facilities and staff were tested three times a week.” from the report
Contact with families
When visits were stopped, the home helped people keep in touch with relatives by video and telephone.
“While the home was closed the service kept people in touch with their families using video calls or phone calls.” from the report
Cleaning and equipment
The home increased cleaning, including frequent touch points, and cleaned shared equipment after use.
“Extra domestic staff had been employed to ensure cleaning was enhanced and extra cleaning of frequent touch points was in place.” from the report
Inspectors raised no specific concerns in this report.
- 01How are people who test positive for COVID-19 isolated, especially if they cannot remain in their own room?
- 02Are staff still tested three times a week, and how often are residents' temperatures and oxygen levels checked?
- 03How are visits booked and how do you make sure relatives follow infection control procedures?
- 04How are shared items such as hoists cleaned after use?
- 05What arrangements are in place to cover shifts when staff are self-isolating?
This was an announced, targeted inspection of infection prevention and control only; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 24 February 2021 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, February 2020
Rated Good; inspectors found kind, personalised care and strong end-of-life support, but the responsive rating fell from Outstanding and some records needed improvement.
This was an unannounced planned inspection on 18 December 2019. Inspectors spoke with people living in the home, relatives, staff and the manager. They observed care and checked care records, medicines, training, recruitment and quality checks.
The overall rating was Good. Safe, Effective, Caring and Well-led were all rated Good. Inspectors found people were protected from abuse, received their medicines safely, had enough support with food and healthcare, and were treated with kindness, dignity and respect.
The home provided personalised activities and detailed end-of-life support. However, the Responsive rating fell from Outstanding at the previous inspection to Good. Inspectors also found that a small number of fluid charts were not totalled correctly and recommended more thorough checking of records.
Kind and respectful care
People and relatives described staff as caring, friendly and compassionate. Staff supported privacy, dignity, independence and involvement in decisions.
“People experienced positive caring relationships with the staff team which reflected their heritage and culture.” from the report
End-of-life support
Staff had specialist training and detailed knowledge about end-of-life care. The home worked with healthcare professionals and supported families to understand what would happen.
“The homes registered manager and staff have successfully retained the Derbyshire End of Life Care Quality Award (DELQA award) for excellent end of life care.” from the report
Personalised activities
Staff used people's life histories, interests, cultures and faiths to plan activities. People could join trips, religious services, music, crafts and social events.
“Staff recorded what was important to people, which helped staff plan and provide individualised care and pastimes based on their preferences.” from the report
Good leadership and oversight
People and staff described the home as open and well managed. Audits, meetings and feedback were used to monitor safety and make improvements.
“The registered manager had excellent oversight of the service and people knew who they were.” from the report
Fluid records
needs fixingA small number of fluid charts were not totalled correctly. Inspectors recommended that records contain complete information and are checked more thoroughly.
“However, one relative told us the fluid charts were not always totalled correctly.” from the report
Mixed views about staffing
minorStaffing rotas showed levels were suitable, but some relatives thought there were fewer staff than before or that more staff would help, particularly when sickness occurred.
“More staff would be advantageous because there seems to be a lot of sickness, two more staff would be good.” from the report
- 01How do you make sure there are enough staff when people’s needs increase or staff are off sick?
- 02What checks are now in place to make sure fluid charts are totalled correctly?
- 03How will you maintain and develop the activities and personalised support that were previously rated Outstanding?
- 04What end-of-life training do staff receive, and how are families involved in planning this care?
- 05How are relatives’ suggestions and concerns recorded, reviewed and acted on?
This was an unannounced planned inspection covering all five CQC questions, including the premises and care provided; the previous inspection was published in July 2017. This explanation was written from the published report of 5 February 2020 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 Tree Care Home Limited
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Cedar Tree Care Home Limited →
- February 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Cedar Tree Care Home Limited →
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- July 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- October 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 27 January 2011.
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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