Background to this inspection
Updated
12 November 2019
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 Care Act 2014.
Inspection team
The inspection was completed by one inspector 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.
Care Homes
Cedar Falls s is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all of this information to plan our inspection.
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.
During the inspection
We spoke with seven people who used the service and two relatives about their experience of the care provided. We spoke with five members of staff including the provider, area, manager, the home manager, senior care and care workers. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
12 November 2019
About the service
Cedar Falls Care Home is a residential care home providing personal care to 38 people aged 65 and over at the time of the inspection. The service can support up to 39 people.
People’s experience of using this service and what we found
Service management and leadership had been inconsistent and areas for improvements were identified in the quality monitoring and accurate record keeping. We found concerns relating to documentation which had not been identified by internal checks and audits. Medicines identified 'as required' or PRN medicines were not being consistently recorded when given.
Accurate information had not been included in people’s risks assessments and their known risks were not accurately recorded, meaning potential for people to receive care which had not met their needs.
Staff knew how to recognise potential abuse and who they should report any concerns to. People had access to equipment that reduced the risk of harm. There were sufficient staff on duty to meet people’s needs.
People had a choice of food and were supported to maintain a healthy diet in line with their needs and preferences. Staff were trained to meet people’s needs and acted promptly to refer people to healthcare professionals when required.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
People enjoyed positive and caring relationships with the staff team and were treated with kindness and respect. People’s independence was promoted as staff were careful not to do things for people they could do for themselves.
People were supported by staff who knew about their needs and routines and ensured these were met and respected. Staff and relatives knew how to complain and were confident that their concerns would be listened to. The provider worked well with partners to ensured people’s needs were met.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk.
Rating at last inspection
The last rating for this service was good (published 16 March 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Enforcement Action
Since the last inspection we recognised that the provider had failed to have a registered manager. This was a breach of regulation.
We have identified a breach in relation to Regulation 17, Good Governance as the provider had not ensured good governance had been maintained to ensure systems were assessed monitored and used to improve the quality and safety of the services provided at this inspection.
Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of governance and safety. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.