Background to this inspection
Updated
19 August 2023
The inspection
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.
Inspection team
The inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Cedar Falls is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. A new manager had recently started working in the home. The manager planned to register with us.
Notice of inspection
The inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since our last inspection, including notifications the provider had sent to us and information we had received from the public. We also gathered feedback from the local authority.
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.
During the inspection
We spoke with 3 people and 9 relatives or friends. We spoke with the manager, the area manager, the clinical lead and 5 care staff. We also spoke with the nominated individual, who is also the provider. We looked at the care records for 11 people. We checked the care people received matched the information in their records. We looked at records relating to the management of the service, including audits carried out within the service and staff recruitment checks.
The nominated individual is responsible for supervising the management of the service on behalf of the provider.
Updated
19 August 2023
About the service
Cedar Falls is a residential and nursing home providing personal care and accommodation for up to 39 people. Older people were living in the home, and some were living with dementia. People have access to their own bedroom along with communal spaces including lounges and gardens. At the time of our inspection there were 27 people living in the home.
People's experience of using this service and what we found
The systems in place were not effective in identifying areas that required improvement. Feedback had been sought from people, however this had not been used to make improvements. Lessons were not consistently being learnt in the home. There was no evidence to show people and those important to them were involved with their care or the reviewing of this.
As people's care was not always reviewed, care plans and risk assessments were out of date and in some instances not in place. Improvements were needed to ensure all people received their medicines as prescribed. Advice from professionals was not always followed as needed.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The home environment required updating, however it was clean and infection control procedures were in place and followed.
There were systems in place to ensure there were enough suitably trained and recruited staff available for people. People were happy with the care they received and felt they were supported with dignity and respect.
People enjoyed the food and were offered a choice. People told us they were happy with the activities provided in the home. There was a complaints policy in place, and this was followed. Staff felt supported by the manager and provider and were able to raise concerns. We were notified by the manager or provider of significant events as they are required to do.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 25 February 2022, and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about staffing levels, risk management, leadership, infection control issues and an incident that had occurred in the home. A decision was made for us to inspect and examine those risks.
Enforcement and Recommendations
We have identified breaches in relation to how risks are managed in the home, how the provider assessed and monitored quality to ensure improvements were consistently made when required. We identified concerns with capacity and following the Mental Capacity Act and that people’s communication needs were not always fully understood.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.