23 September 2022
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 Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
The inspection was carried out by one inspector.
Service and service type
Cedarwood House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cedarwood House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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. At the time of our inspection there was not a registered manager in post. The manager was new to the home and intended to register with CQC following completion of their probation period.
Notice of inspection
This inspection was unannounced.
Inspection activity started on 16 August 2022 and ended on 22 August 2022. We visited the location’s service on 16 August 2022 and 18 August 2022.
What we did before the inspection
We reviewed information we held about the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke to three people that lived at the home and four people’s relatives. We spent time observing the care and support people received from staff. We spoke to eight members of staff including the manager, deputy manager, kitchen assistant, maintenance person, head housekeeper and carers. We reviewed four people’s care plans and multiple medication administration records. We saw a range of records relating to the quality assurance of the service.
23 September 2022
About the service
Cedarwood House is a residential care home providing accommodation and personal care for up to 20 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 17 people using the service.
People’s experience of using this service and what we found
Risks to people had not always been safely managed. Improvements were needed to ensure that people with diabetes were supported safely by staff. Care plans and risk assessments were not up to date and did not always reflect people’s needs. Medicine processes were not always robust. Systems were not in place for checking that staff had given people their medicines as prescribed and medicines had not always been stored correctly.
The management team and most staff were new to the home. More time was needed for this new team to be able to identify issues at the service and take action to make improvements. Audit systems were in place but had not been completed recently. Improvements were needed to documents to ensure that staff were accurately recording the support people received.
There were enough staff to support people and staff were recruited safely. Staff followed infection, prevention and control procedures and the home was clean and hygienic. Staff spoke to people with kindness and respect and people seemed comfortable around staff.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (Published 26 March 2021).
Why we inspected
This inspection was prompted by a review of the information we held about this service.
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.
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 safe care and treatment and governance at this inspection. Please see the action we have told the provider to take at the end of this report.
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.