CQC report explained · a residential care home
What the CQC found at Cedarwood Care Centre
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments and care records were not always up to date or detailed enough to guide safe care. Weight monitoring was inconsistent, although the provider had introduced a new system for nutrition, fluids and weight.
- Effective?
- Requires improvement
- Some staff needed further training and formal supervision was not taking place. Mental capacity assessments were missing for some important decisions, and the home was not designed in a dementia-friendly way.
- Caring?
- Requires improvement
- People and relatives described staff as kind, patient and respectful. However, residents' meetings did not take place, so people did not always have a formal way to discuss choices or concerns.
- Responsive?
- Requires improvement
- Care plans did not consistently involve people or relatives and activities were not planned around people's interests. Communication plans and records of end of life wishes were also not always in place.
- Well-led?
- Requires improvement
- The home lacked effective audits and systems to monitor care, incidents, risks, training and people's views. The provider and manager had begun making changes, but inspectors found that further improvements were required.
What inspectors found, March 2022
Cedarwood Care Centre is rated Requires Improvement; inspectors found caring staff but serious gaps in care planning and oversight.
This was an unannounced inspection on 2 and 3 February 2022. Two inspectors visited the home and a pharmacist inspector worked off site. They spoke with people, staff, a relative and health and social care professionals. They reviewed care records, medicines records, staff files, training information and management records.
Inspectors found that risks were not always assessed or reviewed properly. Care plans often lacked clear guidance for staff. Records about people's weight, food and drink were not always reliable. The home was clean overall and medicines were stored and given safely, but there were some infection and environmental risks, including dirty mop water, an unlocked cupboard containing harmful substances, mould and protruding screws.
People and relatives said staff were kind, respectful and approachable. However, people were not always involved in care reviews, menu choices, activities or end of life planning. Staff training and formal supervision were incomplete. The home had not carried out quality audits since June 2021, so problems were not being identified and corrected reliably.
The overall rating and all five question ratings are Requires Improvement. The previous overall rating was Good, published in June 2021. The provider had started changes after a period without a regular manager, but inspectors said more improvement was needed.
Kind and respectful staff
People and relatives generally described staff as kind, patient and respectful. Inspectors also saw examples of compassionate care.
“People told us staff were kind and caring and treated them with dignity and respect and we observed some examples of staff working in a caring way.” from the report
Medicines support
Medicines were stored safely. Staff explained medicines to people and supported them to take them safely.
“Staff explained to people why they were offering their medicines and supported people to take them safely.” from the report
Support from health professionals
The home worked with social workers, district nurses, pharmacists and other professionals. People were supported to attend appointments and complete follow-up appointments.
“We saw that the provider worked in partnership with several different professionals to ensure that people's needs were met.” from the report
Willingness to improve
The provider and manager were open during the inspection and had started updating care plans and restarting team and house meetings.
“The provider and registered manager were open and transparent during the inspection and demonstrated a willingness to listen and improve.” from the report
Care plans and risk reviews
seriousCare plans and risk assessments were often too brief or out of date. This meant staff might not have the information needed to manage people's risks safely.
“This meant staff could not always manage risks and provide care people needed.” from the report
Weak quality checks
seriousThe provider had not completed audits since June 2021. Important problems with care plans, incidents, risks, training and the environment had not been reliably identified.
“The quality assurance checks in place to drive improvement were not robust.” from the report
Limited involvement in care
needs fixingPeople and relatives were not consistently involved in care planning and reviews. There was also little evidence that people helped choose activities or menus.
“We reviewed seven care records and found no evidence in six records of discussions with people or their families.” from the report
Training and staff supervision
needs fixingSome staff needed further training, including in care planning, risk assessment and safeguarding. Formal supervision was not taking place, so staff concerns and performance might not be addressed promptly.
“Formal staff supervisions were not taking place.” from the report
Environmental safety
seriousInspectors found an unlocked cupboard containing substances harmful if swallowed, mould linked to a broken extractor fan and protruding screws on communal doors.
“This meant that staff and people were at risk of injury.” from the report
- 01How have you made sure every person's care plan and risk assessment is current, detailed and reviewed after changes?
- 02What checks now monitor accidents, incidents, safeguarding, nutrition, medicines and environmental risks?
- 03How do you involve people and relatives in care reviews, menu choices, activities and end of life planning?
- 04Which staff still need training, and how are training, competency and formal supervision being recorded?
- 05What action has been taken in response to the Regulation 17 warning notice?
This was an unannounced inspection covering all five ratings, with particular attention to infection prevention and control under Safe and a specific incident and governance concerns. This explanation was written from the published report of 10 March 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.
What inspectors found, July 2021
Cedarwood Care Centre was rated Good overall; inspectors found safe and responsive care, but the home was not always well-led.
This was an unannounced inspection on 8 and 9 June 2021. Inspectors spoke with people living in the home, a relative and staff. They observed care and checked care plans, medicines, recruitment records and management records.
The home was rated Good overall. Safe and Responsive were rated Good. Inspectors found people were safe, medicines were generally given correctly, infection control measures were suitable and people's care plans reflected their needs and preferences.
Well-led was rated Requires Improvement. Inspectors found that people's feedback was not always gathered effectively. There were missed opportunities for staff to interact with people, and some issues affecting people's experience had not been identified by the home's usual feedback systems.
The inspection followed concerns about neglect and the building being in poor repair. Inspectors found no evidence that people were neglected or that the environment was in poor repair. The overall rating was unchanged from the previous Good rating, although the well-led rating fell from Good to Requires Improvement.
People felt safe
People said staff practice was safe. Inspectors found the home clean and tidy and found no evidence of neglect.
“People told us they felt staff practice was safe.” from the report
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including safe use of protective equipment and support for visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Personalised care plans
Care plans recorded people's likes, dislikes, communication needs, life histories, religious beliefs and important relationships.
“People's care plans contained information about how they liked to be supported. They included people's likes and dislikes.” from the report
Partnership working
Staff worked with GPs, community nurses and other professionals to support people's health and achieve positive outcomes.
“Staff communicated with the GP, community nurses and other professionals when required.” from the report
Feedback was not always picked up
needs fixingThe home's surveys and feedback processes had not identified all concerns about activities and food. Managers only became aware of some issues during the inspection.
“The registered manager had not been made aware of all of these issues and surveys had not always identified them.” from the report
Limited activities
minorSome people said they were bored. Activities had been affected by COVID-19 restrictions, although daily group and one-to-one activities had been introduced.
“Some people told us they were bored. All of the entertainment that was outsourced had been cancelled due to COVID-19 restrictions” from the report
Missed staff interactions
needs fixingInspectors saw staff entering and leaving a room without interacting with the people there over a 20-minute period.
“We observed over a 20-minute period 11 staff enter and leave a room and there was no interaction with any of the 4 people in there.” from the report
Privacy and bedroom access
needs fixingA person had entered other people's bedrooms and taken belongings. The home had not considered how to address this until inspectors raised it.
“There had been no consideration as to how this concern could be addressed.” from the report
Medicine records
needs fixingSome medicine stock records did not balance with the expected stock. Inspectors also found one liquid medicine without an opening date, although it had not been given.
“Some peoples prescribed tablets did not balance with what should have been in stock.” from the report
- 01How do you now gather and act on people's views about activities and culturally appropriate food?
- 02What activities are currently available for people who may become bored or need one-to-one support?
- 03How do you prevent people entering other residents' bedrooms and protect their belongings and privacy?
- 04What checks are now in place to make sure medicine stock records and opening dates are accurate?
- 05How are people whose bedrooms are upstairs supported when the lift is out of order?
The inspection examined concerns about safety and the environment, infection control, and the Safe, Responsive and Well-led questions; Effective and Caring were not given new ratings in this report. This explanation was written from the published report of 8 July 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.
Every inspection of Cedarwood Care Centre
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- March 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2021Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Registered with the Care Quality Commission on 7 February 2014.
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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