CQC report explained · a residential care home
What the CQC found at Cedardale Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2021
Rated Good overall, but Safe Requires Improvement because medicines were not always recorded or given correctly.
Inspectors visited unannounced on 7 and 8 October 2021. They spoke with people living at the home, relatives and staff, and checked care plans, medicines records, staff files, rotas and management records.
People were generally described as safe, well cared for and treated with kindness. Inspectors found enough staff, suitable training, personalised care, support with food and healthcare, and good attention to people's choices, dignity and relationships.
The main problem was medicines management. Records had missed signatures, medicines audits had not been completed recently, and one person received an incorrect dose. The manager acted immediately after the inspection to correct the errors and make improvements.
The overall rating stayed Good, as did Effective, Caring, Responsive and Well-led. Safe fell from Good to Requires Improvement, meaning inspectors found limited assurance in some safety arrangements and an increased risk that people could be harmed.
Kind and respectful care
People and relatives described staff as caring, kind and compassionate. Inspectors observed positive interactions and respect for privacy and dignity.
“People and their relatives told us the support they received was caring , kind and compassionate.” from the report
Personalised support
Care plans covered individual needs and preferences, and staff understood people's routines. People were supported to make choices about their daily lives.
“People were receiving person-centred care and their communication needs were met.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Staff had induction, supervision and training, including the Care Certificate.
“There were enough staff to meet people's care needs.” from the report
Activities and relationships
People were supported to keep in touch with relatives and take part in activities they enjoyed, including singing and reminiscing.
“People had been supported to keep in contact with relatives during COVID-19 pandemic.” from the report
Good risk planning
Individual risk assessments gave staff clear guidance, including for falls and repositioning. Inspectors found that staff followed the guidance checked.
“People's risks were well managed and individualised care plans included risk assessments specific to each person.” from the report
Incorrect medicine dose
seriousOne person was given the wrong dose of a medicine. The error was found during the inspection, although the manager sought healthcare advice and the person had no health implications from it.
“One person was given an incorrect dose of their medicine which was not picked up until inspection.” from the report
Medicines records and audits
needs fixingSome medicine administration records had missing signatures. A recent medicines audit had not been completed, so it had not identified the recording and reporting errors.
“Audits for medicines had not been completed recently which would have highlighted recording and reporting errors identified on inspection.” from the report
Home environment still being improved
minorThe home was undergoing refurbishment, and one relative described it as a little shabby. The manager had plans to continue improvements.
“The home is a bit shabby, but they are trying to make improvements which is good” from the report
- 01What changes have you made to prevent missed signatures on medicines administration records?
- 02How do you now check that medicines are given at the correct dose?
- 03When was the most recent medicines audit completed, and can you explain what it found?
- 04How will you keep us informed if there is a medicines error involving our relative?
- 05Which refurbishment work has been completed since the inspection, and what remains to be done?
This inspection was part of CQC's monitoring of services rated Good and included infection prevention and control, while the report also gave ratings and findings for all five key questions. This explanation was written from the published report of 26 October 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, December 2019
Rated Good; inspectors found kind, safe and well-managed care, but noted a serious incident under investigation and some areas needing improvement.
This was an unannounced inspection on 28 November 2019 by two inspectors. They spoke with people, relatives, managers and staff. They observed care and reviewed care records, staff training, audits and other records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable care planning and kind, respectful support.
The inspection was told about a serious incident that caused an injury. A safeguarding authority was investigating it, so inspectors did not examine what happened. They did examine related risks in people's rooms and were satisfied that action had been taken to reduce further risks.
Inspectors also identified some improvements needed. These included replacing urine-smelling hallway carpets, providing a handwashing facility in the laundry room, adding some best-interest records, improving end-of-life care plans and reviewing activities.
Kind and respectful staff
People and relatives spoke very positively about staff. Inspectors observed kindness, attention, privacy and respect during care.
“People and relatives were very complimentary about the caring nature of the staff and management team at the service.” from the report
Safe staffing and risk support
Inspectors found enough staff to meet people's needs. Risk assessments gave staff clear instructions, and staff responded promptly when people needed help.
“During the inspection we saw that where people needed support this was provided by staff straight away.” from the report
Medicines managed safely
Medicines were stored and given through suitable systems. Records were readable and staff had training and competency checks.
“There were appropriate systems in place to ensure the safe storage and administration of medicines.” from the report
Personalised care and independence
Care plans reflected people's needs, preferences and routines. Staff encouraged people to make choices and do things for themselves.
“People were supported and encouraged to remain as independent as possible and were involved in decisions around their care.” from the report
Open management and improvement
Managers welcomed feedback and used audits, surveys and meetings to make changes. They acted quickly on some issues raised during the inspection.
“There was a robust system in place to assess the quality of care provided.” from the report
Serious incident under investigation
seriousThe inspection was told about an incident in which a person sustained a serious injury. A safeguarding authority was investigating it, and this inspection did not assess the circumstances.
“Following which a person using the service sustained a serious injury.” from the report
Infection control facilities
needs fixingHallway carpets smelled of urine, although replacement carpets had been ordered. The laundry room also had no handwashing facility, with plans to move the laundry area.
“We also identified that the laundry room had no facility for staff to wash their hands.” from the report
Some records needed completing
needs fixingSome best-interest decisions were not in care plans. The manager began reviewing care plans and completing the missing documentation.
“However, some of the best interest decisions were not always present in the care plan.” from the report
End-of-life plans
needs fixingInspectors said care plans needed more information about people's wishes at the end of life. The manager said this would be addressed.
“However, we have fed back that more information was required in the care plans around what people wanted at the end of their life.” from the report
More activities wanted
minorPeople and relatives enjoyed activities but felt there should be more, particularly in the mornings. The manager said activities and outings would be reviewed.
“There are times you come in and they are just sitting in front of the television.” from the report
- 01What was the outcome of the safeguarding investigation into the serious injury mentioned in the report?
- 02Were the hallway carpets replaced and was a handwashing facility provided in the laundry area?
- 03Have all best-interest decisions and end-of-life wishes now been added to people's care plans?
- 04What changes were made to the activities programme, especially morning activities and outings?
- 05How do you currently check that risks for people cared for in their rooms are being managed?
This was an unannounced inspection covering all five key questions, but it did not examine the circumstances of the serious incident because that was subject to a safeguarding investigation. This explanation was written from the published report of 21 December 2019 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 Cedardale Residential Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2021Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementdown from GoodSafe: Requires improvement
- May 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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