Cedar Court Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified one breach of regulation. Systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people. Audits completed were ineffective. Systems and processes in place did not always support learning and improvement. Overall people and relatives spoke positively about the service, the registered manager and staff. The service worked in partnership with health and social care professionals as required.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke positively about working at the service and told us that the management was good. Updates about the service was shared with staff when needed.

There was an organisational structure in place and staff understood their individual roles, responsibilities and the contribution they made to the service.

Staff spoke positively about the management of the service. Management staff recognised staff contributions in a positive way.

The service operated in an open way and the registered manager was visible at all levels and available for people, relatives and staff when needed.

Staff told us they knew how to raise concerns. Staff were reminded about whistleblowing and encouraged to raise any concerns they had. Whistleblowing polices were in place and records showed a local authority representative attended a staff meeting to speak about whistleblowing.

There were procedures in place for people, relatives and staff to raise concerns when needed.

Staff had completed equality, diversity and inclusion training. However, were not aware of people’s equality and diversity needs.

There was an equality and diversity policy in place to help staff would be treated fairly.

The quality of care people received was inconsistent and was not good care at all times. There was a poor culture at the service with a level of complacency and a lack of empathy shown towards people and their care which has been evidenced by people’s and relatives feedback and observed during this assessment.

We found, despite staff having had training, supervisions, monitoring spot checks and team meetings, staff were not always aware of people’s individual health conditions and the risks involved to ensure support was provided safely. Some staff were task focused and demonstrated a lack of compassion towards people especially during mealtimes. Staff showed a complete disregard to people’s personal clothing and personal space. There was a lack of empathy towards people when they were in distress and ensuring people’s dignity was being maintained at all times. Not all staff read the care plans as there appeared to be a two-tiered system in which only senior staff would deal with people’s care plans and the remaining staff would only be completing daily records.

Staff did have the opportunity to raise any issues or concerns they may have had about the service through team meetings and staff surveys. However when concerns had been raised from staff when completing the staff surveys, there was nothing in place to suggest or demonstrate management staff, when alerted to examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff, that this had been addressed quickly.

Systems in place were not robust enough to assess, monitor and improve the quality and safety of the services being provided to people. A number of audits had been completed which covered care plans, unannounced spot checks, kitchen, staffing, medicines, health and safety and infection control. However these audits were ineffective as they were tick box checks and did not identify any issues with the service.

We found significant improvement was needed in relation to incidents and learning, risk assessments, staff deployment and behaviours, recruitment checks, unsuitable and unsafe premises, infection control, medicines, food and drink, mealtime experiences, care records, consent to care and decision making, end of life care, people’s dignity not being maintained, a lack of meaningful activities for people with dementia and information not being provided to people in accessible formats.

The service was registered with a new care provider in 2023; however we found there was inadequate oversight which resulted with people experiencing poor care. Although, it has been a year, the service has failed to make any progress and demonstrated a complete disregard to people and their care. For example, the service failed to implement an effective care planning system, installing a call bell system which can be monitored to ensure people were cared for in a timely manner, appropriate tools for staff to use such as work mobiles and uniforms and the lack of maintenance, refurbishment and décor which has left people living in premises unsuitable and unsafe for them. The service has experienced bed bugs, a scabies outbreak and mice. Records showed there were mouse sightings at the service in June 2024. The registered manager told us that pest control were conducting monthly visits, however these visits were not documented. The service had failed to notify the CQC of this issue and resolve the issue effectively.

People and relatives told us the service worked in partnership with them and other health and social care professionals as required.

Staff and management worked with the external partners such as the local authority commissioners and other health care and social care professionals to provide joined up care.

Systems were in place to enable access to services and deliver care. and treatment. A healthcare professional spoke positively about working with the service. They told us “We have serviced the home for some years now and have always found them to be very professional and approachable. We tend to deal with the management and seniors at the home. They follow all of our procedures and in a timely manner. Any follow ups and issues are dealt with quickly and with kindness and support.”

There were systems in place for staff to feedback about the service using staff surveys, however there was no information which showed areas for improvement identified were actioned.

Systems and processes in place did not support learning and improvement. Where issues had been identified, there was limited actions taken in response. For example, records showed issues raised during resident and relative meetings, staff meetings, surveys and unannounced spot checks. However, there was no information to show the issues raised had been addressed and actions taken to ensure matters were resolved. Lessons learnt had not been identified to help improve the quality of service being provided to people as well as supporting the wellbeing of staff and ensuring poor behaviours and incompetence was managed effectively.