The Cedars

At our last assessment in February 2023, we rated the service requires improvement with a breach of 1 legal regulation. This was because the provider was not ensuring mental capacity requirements were being completed. Following our assessment, the provider sent us an action plan on how they would meet the legal requirements. This assessment was completed to follow up the action plan.

At this assessment we found improvements had been made to mental capacity assessments being completed if needed within people’s care and support plans. However, 1 person had confirmation within their care plan they lacked capacity. No best interest assessments had been completed for them.

We found 1 breach of regulation in relation to good governance at this assessment.

Improvements were needed to people’s care planning information, risk assessments for equipment and mobility needs, best interest decisions, and where medicines posed a flammable risk. Improvements were also needed to demonstrate how personal protective equipment was being handled and disposed of. Improvements to the maintenance of the premises such as area’s of décor requiring updating or repair. Risk assessments were needed for alternative equipment being used whilst the lift was out of service. Not all water safety temperature checks were within a suitable safe range. The providers existing governance arrangements had not identified these shortfalls. This is a breach of good governance.

Regular visits were undertaken by a care home liaison nurse and if needed people could be supported by staff to attend health appointments within the community. Where we were provided with feedback about improvements needed tp attending appointments and to people’s meal experience. We raised this with the registered manager so they could follow this up with people and take any action needed. Positive feedback was provided during the inspection from health care professionals. They said improvements were being made to the service with staff and the management of the service being professional and approachable.

The manager sought people’s views through resident’s meetings. The provider sought staff and relative’s views through satisfaction surveys. Staff felt supported by the registered manager and provider and said it was a nice place to work. The provider undertook safe recruitment procedures of staff and there were no staff vacancies at the time of the inspection.

We have asked the provider for an action plan in response to the concerns found at this assessment.