14 February 2022
During an inspection looking at part of the service
Cedar Grange is a 'care home' providing accommodation across two buildings for up to 31 people who require personal care; some of whom lived with dementia. At the time of the inspection 26 people were living at the service.
People's experience of using this service and what we found
Areas of risk were not always robustly assessed and monitored. Some areas of the service and equipment were not appropriately cleaned, which placed people at risk of infection.
Systems to monitor safety and quality of care had not identified some issues which could negatively impact on people's experiences.
We found some improvements were needed around the administration and recording of medicines. We made a recommendation about this.
People and their relatives were happy with the service. People told us they felt safe living at Cedar Grange, and staff were familiar with the safeguarding procedure.
Staff were recruited safely. There were enough staff to meet people's care needs.
Staff were supported by the management team and worked closely with healthcare professionals to meet people's needs.
The service did not have a manager who was registered with the CQC as required. A new manager had recently been recruited by the provider.
The manager had sought some feedback from people’s relatives following this inspection. Staff were updated about changes to people's needs and any changes to the service.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 22 March 2019).
Why we inspected
We initially carried out an announced IPC outbreak; this was to follow up on IPC arrangements. However, additional concerns were identified and it was agreed that the inspection would be expanded, as a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We looked at IPC measures under the 'safe' key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
We found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cedar Grange on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment and good governance of the service at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.