Cedar Court Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified four breaches of regulations. Risks to people’s health and safety were not effectively assessed, staff were not effectively deployed to meet people’s needs, recruitment processes were not operating effectively, medicines were not being managed safely, accidents and incidents were not managed effectively and lessons were not learnt to improve the safety for people. Infection control practices were poor, and the premises were unsafe. People and relatives told us they felt safe using the service. There were safeguarding polices and procedures in place to respond to and protect people’s welfare.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us they were informed of incidents at the service and actions were taken in response. A relative told us “I’m happy with the care [person] receives. They’ve had falls, but they let me know straight away and the protocols they are following.” Another relative told us “When [person] has fallen, they contact the doctor, or ambulance and then are straight on to me.”

Learning was not effectively disseminated for staff to safely manage incidents and embed best practice to reduce further reoccurrence of incidents. Incident forms were completed by staff which showed actions taken in response to incidents including notifying relevant healthcare professionals. However, records contained limited detail of incidents being investigated to determine how incidents may have occurred. For example, one person was assessed as being at high risk of falls. Their care plan stated staff are to ensure person is wearing appropriate footwear. However, throughout the site visit, the person was observed walking around in socks. Records showed the person experienced falls on the 11/10/2024, 12/10/24, 13/10/24, 26/10/24 and 27/10/24. This was five falls in one month, three of which were in the hallway which was not identified as a possible theme and effective measures put in place to keep the person safe from falling so frequently.

A system was in place to record and respond to incidents, however incidents were not managed effectively at the service. This placed people at continual risk of harm. Records showed a high number of incidents between September and November 2024. For example 35 falls had occurred and there were 19 incidents in relation to skin integrity.

Records showed some analysis had been undertaken to identify the types of incidents occurring, staff had received falls training and sensor mats were in place for people. However these measures were ineffective as the number of falls remained high at the service and people were at continued risk of unavoidable harm.

During the site visit, two people experienced a fall. We also observed people were not wearing appropriate footwear and were walking around with socks on laminated floors which could increase the risks of slips and falls. We raised this with the registered manager who told us some people did not like to wear shoes; however the service had not explored any alternative footwear for people to be encouraged and supported to wear and help protect and maintain their safety.

People and their relatives told us the service worked with other agencies and health professionals to ensure ongoing care and support.

There was a process in place for staff to contact and access health and social care professionals when people needed support with their care and treatment.

The service worked with other health and social care professionals to support smooth transitions when people moved between different services.

People and relatives told us they felt safe using the service. A person told us “The carers make me feel secure because they are there for me.” Another person told us “I feel secure because the girls are nice to me.” A relative told us “They [staff] are so caring here, and I know [person] is safe and comfortable. They are ‘full on’ supporting them.”

Staff had completed safeguarding training and were aware of the different types of abuse and reporting procedures to follow if they had any concerns of abuse.

There were systems in place to protect people from the risk of abuse. There were safeguarding and whistleblowing policies in place to report potential abuse.

Records showed safeguarding concerns were investigated by the service which involved people, relatives and other healthcare professionals including the local safeguarding teams to protect people’s welfare.

Risks to people were not always identified and managed to maintain people’s safety.

We spoke with staff and they were not always aware of people’s individual health conditions and give us adequate information about risks to people including choking, hypoglycaemia, epilepsy, stroke, autistic traits and Parkinsons. For example, two staff members did not know what hypoglycaemia was and the action to take if people had an episode. One staff member told us no one living at the home had Parkinsons and did not know what it was. Three staff members did not know all the people living at the home with Parkinsons and one of these staff told us they had only read about Parkinsons in books and never seen anyone with symptoms.

Risk assessments were not always in place or were inadequate in detail and did not include information about how to minimise risks and maintain people’s safety in accordance with people’s specific needs. For example, risk assessments for two people at risk of choking did not have guidance for staff on how to minimise the risk of choking and actions staff should take in case people did choke.

For two people who had epilepsy, there was no guidance for staff on how to provide support appropriately and safely if and when people did experience a seizure. We were sent updated risk assessments; however these were not sufficient in detail and included generic information that was not specific to people’s individual needs.

For two people requiring the use of mobility aids such as a hoist, there was limited information about the safe practice and risks in relation to using mobility aids and the appropriate moving and handling techniques required by staff to ensure this was done safely.

There were no risk assessments in place for three people with dementia who would ‘walk with purpose,’ to ensure people’s safety when they did.

The risk assessment for one person who smoked in the garden did not include all the risks and guidance to mitigate risks such as ensuring the cigarette had been safely extinguished and how the person should be supervised and monitored whilst smoking.

Records showed an incident where a person had locked themselves in their room. There was no risk assessment in place to ensure this was managed safely and to mitigate the risk of further occurrence.

There was no risk assessment in place for a person who used a topical ointment which was potentially flammable to ensure risks were mitigated and this was managed safely.

People using the service and relatives told us that the service was in need of repair and in parts did not feel safe. A person told us “My TV isn’t quite right, and they say they are going to look at it. I hope it gets done sooner than my light in the bathroom. I have waited a long time.” A relative told us “The place is shabby in many areas. Here in [person’s] room cold water runs out of the hot tap for ages. The doors to the toilet are filled and need painting. It’s not nice.” Another relative told us “The floor in the toilet needs replacing.” A third relative told us “My plea is for the place to be decorated, including [person’s] gloomy room. The en-suite desperately needs updating.” A fourth relative told us “I wasn’t happy with the security on [person’s] patio door. It couldn’t be locked and had someone come in and walk through. I put some furniture up against the door outside. Then I got these security locks you turn, so got one and l now it’s kept locked, unless [person] wants some air.”

Safety checks including fire, water temperatures, electrical and gas checks were carried out to ensure equipment was safe for use. However, health and safety and infection control checks were ineffective as they failed to identify the issues in relation to the premises which left people in an environment which was not safe and clean.

During the site visit, we observed staff wearing different types of clothing from tunics to casual clothing which was inappropriate for a care home setting. It was also difficult to differentiate between staff and their roles which may have a negative impact on people with dementia. We discussed this with the registered manager and provider who told us they were in the process of ordering new uniforms for all staff which would be colour co-ordinated to differentiate the roles of staff.

The service was not clean, properly maintained and did not present a dementia friendly environment. People’s doors were painted different colours. However, the premises appearance was tired and dated. There was limited signage and contrasting colours that could help people with their memory and assist people to recognise and navigate around the service. The walls including people’s bedrooms were all painted the same colour which made it difficult to differentiate between different parts of the service.

The premises presented a ‘dormitory’ type feel and a potential closed culture. For example, during mid morning, we observed curtains were still drawn in people’s rooms and throughout the site visit, most of people’s doors were kept shut. Without, knocking it was difficult to establish whether people were in their rooms or not. Many of the rooms did not have a TV or radio and had basic furnishings such as a bed and cupboard only. Some people did have personalised items such as photos, but many rooms were bare and sterile and lacked any décor.

Communal toilets and sinks were dirty, and some sinks were cracked. One bathroom had a broken shower dispenser with the broken cover left on the sink. Communal bathrooms were being used for storage for items such as a sofa chair, a laundry trolley, mattresses, pillows and hoist. We observed items stored in the stairwells such as a weight chair, zimmer frame, hoover and trolley.

Several of the ensuite facilities for people were in need of attention. Issues included repairs to door frames, which had not been sanded and painted. Some of the doors were damaged or needed replacing. For example, ensuite bathroom doors had holes in them, and some had been filled in with Polyfilla and left. Several rooms had a noticeable gap between the edges of the flooring and the skirting, resulting in any residue going into gaps.

People experienced inconsistencies with the quality of care they received. We received mixed feedback about staffing levels and the lack of availability of staff. A person told us “If I need help, there’s someone around and I call for them” and a relative told us “In the lounge there is a carer with residents.”

However, relatives told us “I take [person] in the lounge for company. There have been times when there was no carer with them. I would say once it was 15 minutes before one arrived.” Another relative told us “There have been occasions when there was no carer in the lounge with residents.” A third relative told us “I have noticed there is not always a carer in the lounge: it might be they are taking someone to the toilet, but someone else should cover.”

People and relatives also told us, at times they would have to find staff when needed due to staff not being available. A relative told us “Generally, there is someone about but there are moments when no one is about in the corridors. Once I needed someone for [person],..and ended up going to the kitchen.” Another relative told us “If I need to find a carer, I can usually find one in the common room and if necessary, ask a cleaner if she knows where a carer is.”

People and relatives told us some staff tended to be more task focused rather than positively engaging with people. A relative told us “There’s usually a carer in the lounge with the people there. They tend to pop in and out. Otherwise there might be someone in there, writing up their notes, so not engaging with the residents.” Another relative told us “Carers tend to be very busy and don’t often have the chance to engage with residents.” A third relative told us “Many carers are lovely, but there’s no doubt, some are just focused on it being a job.”

Staff told us there was not always enough staff to meet people’s needs. When asked about staffing levels, three staff members told us there was not always enough staff, especially at night or in the lounges. A staff member told us people were left unsupervised in the lounge areas and another staff member told us there could be more staff as they had to support more than one person at a time at lunchtime.

Staff completed an induction programme based on the Care Certificate. The Care Certificate is the benchmark that has been set for the induction standard for people working in care. Staff also completed training the provider considered mandatory in areas such as health and safety, moving and handling, food safety and hygiene, safeguarding and fire safety. Staff were supported through supervisions and appraisals which enabled them to discuss their personal development.

Records showed staffing levels were assessed based on people’s needs. The registered manager told us they considered staffing levels to be above expected, and no agency staff were used. However, staff were not effectively deployed to ensure sufficient numbers of suitable staff were available to meet people’s needs at all times. Relatives and staff told us people were being left alone in communal areas and there was not enough staff to support people at night and lunchtimes. During the site visit, we observed both instances of staff not being in the lounge areas with people, as well as times when there was no staff about in the corridors and staff having to support more than one person at a time during lunchtimes.

A group of staff would smoke together outside which meant people were at risk of being left with insufficient staffing and their safety compromised. This had also been observed by relatives. A relative told us “I have noticed you get clusters of staff who smoke in the garden at the front of the building.”

Recruitment processes were not effectively implemented to ensure staff were suitable. We reviewed 6 staff files. 3 staff files had gaps in staff employment history with no satisfactory written explanation of these gaps. For a staff member, dates of employment were listed but not the years. There were two instances where references had been obtained from sources not listed in their recruitment records with no written explanation of reasons why.

Interview notes for all six staff members showed scoring had not been completed which assessed and confirmed their suitability and competency for the roles applied for. Therefore, we could not be assured the recruitment process was robust enough to ensure staff were competent and of good character.

Peopleand relatives told us people’s rooms were generally kept clean. A person told us “My room is kept clean,” another person told us “My room is cleaned every day.” A relative told us “The room is clean, and the shelves are wiped.” However one relative did tell us “My one complaint is the cleanliness. While they mop every day, I notice that bits of dust and dirt end up in corners and under things.”

Relatives also told us of concerns in relation to people’s clothing. A relative told us “The clothes are clean on each day. They choose them for [person] each day, although they are sometimes not their clothes and some of theirs are missing.” Another relative told us “Sometimes [person] has not been wearing any pants and is wearing clothes that are not theirs.” A third relative told us [person] is often wearing clothes belonging to someone else.”

Staff completed infection control training and wore personal protective equipment (PPE) when providing support to people. However, three staff members told us the home was not clean, and one staff member told us that there were offensive odours.

The premises were not always kept clean and hygienic and at times left in an undignified state. Over the past year, the service has experienced bed bugs, a scabies outbreak and mice; the service has taken actions in response to these issues.

There were cleaners at the service, however we observed bedrooms were not clean and tidy with bits of tissue on the floor and wardrobe doors being left wide open. At mid morning, people’s bedrooms had not been cleaned, and many ensuite toilets had not been flushed after use which meant there was an unpleasant odour in many bedrooms. People’s ensuite bathrooms were untidy and cluttered, bins had not been emptied and left with soiled continence pads. Packs of continence pads were left out on side tables in people’s bedrooms. Topical prescribed creams were not stored securely in people’s rooms.

We observed poor practice by staff in the laundry room who demonstrated an uncaring attitude and lack of respect for people’s personal items. People’s clothes were left on the floor. All laundry including soiled laundry were thrown and piled up in one basket. They were not separated into colour coded laundry baskets which is an infection control hazard. We also observed a cat in the laundry room which staff told us would often come into the laundry room. Piles of laundry was stored on top of the tables, in boxes, drawers and random baskets under the table. We observed a random pile of clothes all folded up. A staff member told us the clothes belonged to a resident who were unable to maintain their own clothes. This meant the person was totally dependent on staff bringing their clothes to them, unaware their clothes were kept in a disrespectful manner.

People’s underwear and socks was stored together in communal baskets which is poor practice in relation to personal hygiene. We observed a staff member grab a bunch of socks for people they were not aware of which socks belonged to which person but went ahead to change people’s socks that may not belong to them.

People and relatives told us they were supported with their medicines. A person told us “I get my medicine when I should and there’s never a problem with it.” Another person told us “They give me my medicines and make sure I take them.” Relatives told us “[Person] gets their medicine when they should.” Another relative told us “After they give [person] their medication, they check they have taken it.”

Despite there being medicine policies in place and staff being competency assessed and trained in medicines, there were a range of medicines matters that required improvement.

We observed poor practice by staff when administering medicines. For example, observed a staff member was secondary dispensing medicines for a person. Secondary dispensing is widely regarded as not good practice and should be avoided where possible. Where there is a need for secondary dispensary, a standard operating procedure and risk assessment should be in place. However, these were not in place to ensure this was managed safely. Medicines were decanted in paper packets which was not in line with their medicines policy which stated medicines should be suppled in original packs.

We observed a carer recording a medicine as administered before it was given to the person. The staff member told us they knew people well and would only record this way where they knew they would take them.

Staff did not always administer medicines safely in line with the prescribers’ instructions. For example, the prescriber informed the service to stop administering a statin medicine to a person due to an interaction with an antibiotic they were prescribed. Records showed staff did not follow this instruction and the statin medicine was recorded as being given which placed the person at risk of adverse side effects.

There was no effective process in place to support people on time critical medicines and ensure that medicines were being given on time and every time. We raised this with the registered manager and on the second day of the onsite visit, information was displayed in the medicines room which showed people who needed medicines at specific times and alarms were set up on staff members mobile phones to alert them when these medicines needed to be administered.

Medicines were not always managed safely. For example, some people were diabetic and insulin dependent. District nurses (DN) administered the insulin and kept separate records of this. However, there was no specific dietary information in people’s care records and the responsibilities of staff on how to deal with hypoglycaemia. We were advised there should be rescue packs of high sugar preparations stored in the cupboard, but this was not the case. We raised this with the senior staff member who spoke to the GP and glucogels were promptly prescribed for people. Staff had not received training for checking blood sugars and identifying hypoglycaemia. Therefore, we could not be assured there were effective processes in place to manage people’s diabetic needs safely.

Homely remedies were not recorded in line with the services policy. The policy advised records should be made on the reverse of medicines administration records (MARs). However, we found homely medicines were recorded in a separate notebook, mainly for paracetamol. There was a risk that people would be given duplicate doses if doses were not recorded in the area as defined by their policy.

Medicines were not always stored or disposed of safely and securely. The service did not store controlled drugs (CD) for disposal in line with legislation. We found a schedule 3 controlled drugs requiring safe custody in the medicines return box. Controlled drugs requiring safe custody that are awaiting destruction should be stored in the CD safe, segregated from other controlled drugs. We also found insulin pens and an anticoagulant medicine stored together in an unlocked cupboard.