CQC report explained · a residential care home
What the CQC found at The Cedars
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2023
The Cedars is rated Requires Improvement; inspectors found kind care and better staffing, but consent, care records and oversight still need work, and the home is no longer in special measures.
Inspectors visited unannounced on 21 and 23 February 2023. They spoke with people, staff, relatives and health professionals. They also observed care and checked care records, medicine records, recruitment files and management records.
The home had improved since its previous inspection. Fire safety actions had been completed, staffing and recruitment had improved, and people were treated kindly and with respect. People said they felt safe and were generally positive about staff and activities.
Important problems remained. Consent and mental capacity checks were not always completed properly. Some care plans were generic or contradictory, and medicine records and quality checks were not always reliable. The home breached Regulation 11 about consent.
The overall rating changed from Inadequate to Requires Improvement. The home was no longer in special measures, but the CQC said further improvements were needed.
Improved staffing
The home had a full staff team, did not use agency staff and had improved recruitment checks. People and staff said staffing levels were good.
“The home had a full staff team and did not use any agency staff.” from the report
Kind and respectful care
Inspectors saw staff treating people with dignity and respect. People and relatives spoke positively about the staff and the atmosphere.
“There was a relaxed and friendly atmosphere at the service. People were smiling and laughing with staff.” from the report
Activities and independence
People were supported to choose how they spent their day, take part in activities and go out when they wished.
“We observed staff dancing with a person, reading books with someone else and doing a quiz with 2 other people.” from the report
Fire safety improved
Actions required by the fire service had been completed. Fire safety checks and personal emergency evacuation plans were in place.
“Actions required by the fire service had been completed.” from the report
Care plans were not always accurate
needs fixingSome plans used generic wording or gave conflicting information about people's preferences and needs. This could make it harder for staff to provide consistently personalised care.
“The care planning system used generic statements, and these had not always been personalised.” from the report
Medicine records
needs fixingMedicine key arrangements and homely remedies did not always follow the home's policy. Records did not show that some patches were rotated as recommended.
“The providers policy was not always followed in relation to the holding of the medicine keys and the management of homely remedies.” from the report
Quality oversight
needs fixingAudits had improved but did not always identify or progress important problems. Some safeguarding concerns were not reported to the CQC as required.
“Further improvements were needed to ensure audits identified and progressed the quality and requirements in areas such as care planning, food and fluids and the Mental Capacity Act 2005.” from the report
- 01How do you now assess capacity and record consent for each specific area of care?
- 02How are best interest decisions recorded, and how do you show that less restrictive options were considered?
- 03What has changed in care plans to remove generic or contradictory information?
- 04How are medicine audits checking patch rotation, medicine keys and homely remedies?
- 05Who is currently responsible for management, and how are safeguarding concerns reported to the CQC?
This was an unannounced follow-up inspection after the previous Inadequate rating, covering the overall service and infection prevention and control, with ratings given for all five key questions. This explanation was written from the published report of 18 April 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, October 2022
Rated Inadequate and remains in special measures; inspectors found improvements, but ongoing safety, recruitment and management failures.
This was an unannounced inspection on 2 August 2022 by three inspectors. They spoke with six people, four staff members and the management team. They also checked care records, medicines records, one staff recruitment file, maintenance records and management records.
The home had improved since the previous inspection in June 2022. Medicines records were complete, staffing levels had increased, safeguarding concerns were being reported, and some care plans and the environment had improved.
However, important problems remained. Some people's risk assessments were incomplete, fire safety documents were outstanding, recruitment checks were not fully reliable, and quality checks did not consistently identify or follow up problems. The home did not have a registered manager in post.
The overall rating stayed Inadequate. Safe and well-led were both rated Requires Improvement. The home remains in special measures, so the CQC will continue monitoring it and expects significant improvements.
Medicines records
Inspectors found medicines records were completed correctly, with no gaps in signatures. Storage, temperature checks and staff competency checks had also improved.
“We looked through people's medicines records and found these had been completed correctly, with no gaps in signatures.” from the report
Safeguarding reports
The provider was reporting safeguarding incidents to the local authority. Staff understood how to report concerns.
“We found evidence that since the last inspection, the provider had reported safeguarding events when they occurred.” from the report
Staffing improvements
Staffing levels had increased, including new activity coordinator roles. People and staff told inspectors staffing levels were good, and call bells were answered promptly.
“The inspection day was calm and well organised. The dining room tables had been laid ready for lunch. Call bells were answered promptly.” from the report
Improved food hygiene rating
The home had addressed earlier food safety concerns and had received a five-star food hygiene rating.
“The food standards agency had revisited the home on the 31 July 2022. The home had now been awarded 5 stars.” from the report
Missing risk assessments
seriousSome people's care records and risk assessments still needed review. Inspectors found no risk assessment for one person who had fallen three times and another person who vaped in their bedroom.
“One person for example who had fallen on three occasions, did not have a risk assessment in place in relation to minimising the risks in relation to falls.” from the report
Fire safety documents outstanding
seriousThe annual fire risk assessment was still outstanding and the emergency evacuation plan needed review. Other fire safety actions also remained incomplete.
“Although improvements had been made some actions remained outstanding. This included for example, the fire risk assessment remained outstanding and the emergency evacuation plan was in need of review.” from the report
Recruitment checks
seriousThe provider had not yet shown enough evidence that safe recruitment systems were fully embedded. A new recruit's records had not been put into a staff file.
“Further improvements were needed to ensure that a safe system of recruitment was in place. We did not find enough evidence to feel assured this had been fully embedded.” from the report
Weak quality monitoring
needs fixingAudits did not always identify problems or make sure actions were completed. Six care plans still needed review, and there were no infection control audits.
“Some audits had identified actions and shortfalls. However, there was still a danger the actions identified from each audit could get lost and not followed up.” from the report
No registered manager
needs fixingThere was no manager registered with the CQC when inspectors visited. The provider was interviewing for one.
“The home did not have a manager in post who was registered with the Care Quality Commission.” from the report
- 01What risk assessments are now in place for people who may fall, vape or have other specific risks?
- 02Has the annual fire risk assessment and emergency evacuation plan now been completed and checked?
- 03What recruitment checks are completed before new staff start, and are all records kept in staff files?
- 04Who is currently responsible for management while there is no registered manager?
- 05How are outstanding actions from audits recorded, monitored and checked as completed?
This was an unannounced, focused inspection prompted by concerns about safety; inspectors rated Safe and Well-led only, while the other three key-question ratings were not given in this report. This explanation was written from the published report of 13 October 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.
Every inspection of The Cedars
9 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- April 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2022Inadequatestayed InadequateSafe: Requires improvementWell-led: Requires improvement
- August 2022Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvement
- February 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2021
Registered with the Care Quality Commission on 13 July 2021.
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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23 live-in carers within about an hour of North Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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