CQC report explained · a residential care home
What the CQC found at The Cedars Residential Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention and control, including PPE, testing, cleaning and outbreak management. They found visiting information had not been communicated effectively to all relatives and visitors, and admission COVID-19 results were not always fully recorded.
- Effective?
- Good
- This was not assessed in this targeted inspection.
- Caring?
- Good
- This was not assessed in this targeted inspection.
- Responsive?
- Good
- This was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This was not assessed as a separate question in this targeted inspection, although inspectors noted infection-control audits and up-to-date policies.
What inspectors found, March 2022
Inspected but not rated; inspectors found good infection-control practice but weaknesses in communicating visits and recording admission test results.
This was a targeted inspection on 17 February 2022. It focused on infection prevention and control during the home’s response to COVID-19 outbreaks. Inspectors also asked about staffing pressures.
Inspectors found the home was clean and hygienic. Staff had suitable protective equipment, training and regular hand hygiene checks. Policies, risk assessments and testing arrangements were up to date.
There were two issues to improve. Visiting arrangements had not been clearly explained to all relatives and visitors. Negative COVID-19 results for new admissions were requested, but were not always fully recorded.
The home was inspected but not rated. This means the report does not provide a full overall quality rating or ratings for all five areas of care.
Clean environment
The home was clean and hygienic, with schedules for frequent cleaning. Enhanced cleaning had also taken place during a recent COVID-19 outbreak.
“The home was clean and hygienic. There were schedules in place to ensure frequent cleaning took place.” from the report
Protective equipment and training
Staff had an ongoing supply of suitable PPE and had training in its use. Hand hygiene audits were carried out regularly.
“The provider had ensured staff had an ongoing supply of appropriate personal protective equipment (PPE).” from the report
Up-to-date infection controls
COVID-19 policies, procedures and risk assessments were current. Infection-control audits gave the registered manager oversight.
“Policies, procedures and risk assessments related to COVID-19 were up to date which supported staff to keep people safe.” from the report
Testing and outbreak arrangements
The home had systems for regular testing of people using the service and staff. Inspectors were assured that outbreaks could be prevented or managed effectively.
“There were systems in place to ensure people and staff undertook regular testing as per current guidance.” from the report
Visiting information
needs fixingThe home’s visiting policy allowed some visits during an outbreak, but this had not been clearly explained to all relatives and visitors. The manager was putting further guidance in place.
“this had not been effectively communicated to all relatives and visitors.” from the report
Admission records
needs fixingA negative COVID-19 result was requested for new admissions, but the result was not always fully recorded. Inspectors signposted the provider to resources to improve this approach.
“a negative COVID-19 result was requested in line with guidance, this was not always fully recorded.” from the report
- 01How do you now explain visiting rules to relatives and visitors during an outbreak?
- 02How can a resident nominate an essential care giver, and what visits are currently allowed?
- 03How do you record negative COVID-19 results for people admitted to the home?
- 04What staffing pressures were present at the inspection, and how were their effects managed?
- 05What infection-control audits and hand hygiene checks are carried out now?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection of all five quality areas and the service was inspected but not rated. This explanation was written from the published report of 23 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, January 2020
Rated Good overall; inspectors found kind, safe care, but the home’s leadership and record-keeping require improvement.
This was an unannounced inspection on 2 January 2020. Inspectors spoke with people living in the home, relatives and staff. They observed care and checked care plans, medicines records, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. People generally felt safe and well cared for. Staff treated people kindly, knew them well and supported their choices, health needs and activities.
The home was rated Requires Improvement for Well-led. Inspectors found weaknesses in record-keeping, communication and the follow-up of problems found through checks. The overall rating had improved from Requires Improvement at the previous inspection.
People felt safe
People told inspectors they felt safe. There were generally enough staff, and the use of agency staff had greatly reduced, giving people more consistency.
“People felt safe living at The Cedars and their experience of using the service was overall positive.” from the report
Kind and respectful care
Inspectors observed warm, person-centred interactions. Staff knew people well and supported their dignity, choices and independence.
“Staff treated people with dignity and kindness. We observed warm person-centred interactions between people and staff, which showed they knew each other well.” from the report
Personalised care plans
Care plans had been reviewed and improved. They included people's backgrounds, interests, abilities and preferred ways of receiving support.
“People's care plans included a detailed life story that described their individual backgrounds and interests.” from the report
Improving activities
The home had two activities coordinators and offered a range of activities. Staff were also developing links with local schools and the wider community.
“There was a variety of activities for people to get involved in. Two activities coordinators were now in post, to help provide a more varied programme” from the report
Medicines checks
needs fixingMedicine errors had reduced, but staff competency checks were not always completed or reviewed promptly when concerns were identified. Inspectors recommended continued review of safe medicines practice.
“However, the service needed to ensure staff's medication competencies were completed regularly and when needed.” from the report
Weak follow-up of problems
needs fixingThe home had audits and checks, but did not always act robustly or quickly enough when they identified problems. This included following up medicines competency checks.
“However, at times the service needed to be more effective and robust at making improvements following issues identified by checks or those raised by people and their families.” from the report
Inconsistent records
minorSome care information and staff supervision records were not consistent or recorded appropriately. Inspectors said this had not affected the safety or quality of care at the time.
“A few areas of record-keeping needed to be improved, to ensure some person-centred information was consistent and staff supervisions were completed and recorded appropriately.” from the report
Communication and equipment
needs fixingSome relatives said communication was not always reliable, especially when health information needed to be passed between staff. Relatives also raised concerns about equipment and furnishings.
“Relatives felt that at times communication was not effective, for example if information from health professionals needed to be handed over between staff.” from the report
- 01How often are staff medicine competencies now checked, and what happens if a competency concern is found?
- 02How do you make sure information from health professionals is handed over reliably between shifts?
- 03What action has been taken to improve the equipment and furnishings that relatives raised concerns about?
- 04How are care plans and staff supervision records checked for accuracy and completeness?
- 05How often are meetings now held for residents, relatives and staff, and how are their suggestions followed up?
This was an unannounced inspection covering all five CQC questions, including the premises and the care provided; the previous overall rating was Requires Improvement. This explanation was written from the published report of 22 January 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 The Cedars Residential Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at The Cedars Residential Care Home →
- January 2020GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at The Cedars Residential Care Home →
- January 2019
Registered with the Care Quality Commission on 16 January 2019.
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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