Cedarwood House Care Home

We undertook this full assessment due to concerns we had received relating to a recent safeguarding incident and to look at the governance of the service as there had been no registered manager since 19 February 2022.

The provider was previously in breach of the legal regulations in relation to safety and risk management and governance. Improvements were found at this assessment, and the provider was no longer in breach of these regulations. However, improvements still needed to be made.

We found improvements had been made with care plans and risk assessments. Risk assessments were now in place however some did lack detail. Accidents and incidents were now being reported fully with some evidence of trends being analysed and details being shared with staff. Personal emergency evacuation plans (PEEPs) were now fully in place. Staff had been safely recruited and were supported with ongoing supervisions meetings however there was not always enough staff to meet people’s needs. It had been agreed that an extra member of staff be used for the day shift, but this was not always happening, resulting in staff being stretched and people’s immediate needs not always being met Infection control and medicines were managed.

We found improvements had been made to the governance of the service. Auditing processes were in place, but we found some areas of auditing still needed improving. For example, trends from daily notes on care plans and some sections within care plans required oversight to highlight gaps. Mental capacity assessments had improved from the last assessment however there were still some gaps found relating to consent to personal care. This area required improvement. The service was still without a registered manager although a manager from the service sister home was overseeing the home, and the longer-term plan was for them to register and then to manage 2 homes.

People’s needs were assessed thoroughly before moving into the home. These needs were reviewed however we found a gap with regard ongoing oral health management with some conflicting evidence within care plans. Other recognised tools were being used effectively to manage people weights and susceptibility to developing pressure sores. The service worked well with other health and social care professionals and people’s nutrition and hydration needs were met.

People’s individual wishes and needs were not consistently responded to due to the apparent shortage of staff at certain times of the day. People were treated with kindness and compassion by a staffing team that knew them well. People’s independence was encouraged and safely supported. Staff told us of a supportive management team who encouraged a positive work life balance.

Staffing numbers further impacted on activities for people. No activities coordinator was employed and there was a lack of daily stimulation for people. Although care was delivered in a person-centered way this was not always reflected in care plans with personal histories and some preferred communication pages being brief or missing. However, people’s communication needs were met by a staffing team that knew the most appropriate way to convey messages to people, some of whom were non-verbal. A complaint policy was in place and accessible. Staff were aware of the specific needs associated with end-of-life support.