Cedarwood Care Centre

Updated 10 March 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was undertaken by two inspectors on site and a pharmacist inspector off site.

Service and service type

Cederwood Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider completed a provider information return on 10 March 2021. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. This information helps support our inspections. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experience of the care provided. We also spoke with five members of staff; a senior care worker, a cook and three care workers. Additionally, we spoke to the registered manager, the area manager, and the provider.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records as well as audits and policies. We spoke with one relative and three professionals who regularly have contact with people who use the service.

Updated 10 March 2022

About the service

Cederwood Care Centre is a residential care home providing personal care for up to 38 older people and/or people with dementia. At the time of inspection 22 people were living in the home with 16 vacancies.

Cederwood Care Centre accommodates up to 38 people in one adapted building. The accommodation is over two floors with a lift connecting the ground floor to the first floor. There is a dedicated managers office located on the ground floor and a staff room located in the converted loft area. There are usually five staff on day shifts including a senior carer as well as the registered manager. Nights are covered by three staff with managers available ‘on-call’ as required.

People’s experience of using this service and what we found

The quality assurance checks in place to drive improvement were not robust. They had not ensured the safety of care was sufficiently monitored. The provider told us that they had not completed audits since June 2021.

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. However, there was a lack of systems in place to ensure the home was consistently caring and people were fully involved in their care.

People did not always receive person centred care and there were not always enough activities available for people to enjoy. People and relatives were not always consulted about their wishes about the end of their life and were not involved in reviews of their care. People, relatives and staff were not always given the opportunity to provide feedback.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests.

People, staff and relatives knew how to complain. The nominated individual understood their responsibilities under the duty of candour.

From 11 November 2021 registered persons must make sure all care home workers and other professionals visiting the service are fully vaccinated against COVID-19, unless they have an exemption or there is an emergency. We checked to make sure the service was meeting this requirement. We found the service had effective measures in place to make sure this requirement was being met.

Rating at last inspection

The last rating for this service was good (published 08 June 2021).

The service was registered on 14 February 2014.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

The inspection was prompted in part by notification of a specific incident. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe and Well-Led sections of this full report.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cederwood Care Centre on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to regulation 12, safe care and treatment and regulation 17, governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.