3 July 2023
During an inspection looking at part of the service
People's experience of using this service and what we found
People received safe care and support. Improvements had been made to the assessment and ongoing review systems and processes of people’s individual care and treatment needs. Additional monitoring of quality and safety had increased, and management oversight and leadership had improved risk management.
Overall, positive feedback was received from relatives about the care and treatment of their family members. Relatives reflected on improvements made at the service in relation to better communication, management, and leadership.
People received their prescribed medicines safely and when required. The provider’s medicines management and monitoring procedures had been reviewed and improvements made.
Improvements had been made to the guidance provided for staff about how to meet people’s needs. Where we identified minor shortfalls in relation to some inconsistencies in information, the management team took immediate action.
People were protected as far as possible, from avoidable harm and abuse. Staff had received safeguarding training and understood their responsibilities to protect people.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way. Improvements were ongoing in relation to the assessment process of people’s mental capacity.
Staff deployment was based on people’s dependency needs and was regularly reviewed. Staff recruitment had increased, resulting in a reduction in the use of agency staff. This promoted increased consistency and continuity in care and treatment.
Staff had been safely recruited and had received refresher training and their competency assessed. Staff were found to be knowledgeable about people’s individual care and treatment needs. Staff spoke positively about the improvements made at the service and how they felt well supported.
Observations of staff engagement with people was positive. There was a calm, organised and relaxed atmosphere at the service.
The service was overall clean and hygienic. Some shortfalls with storage of equipment and products were identified. This was discussed with the management team.
The provider had developed their procedures in reviewing and learning from accidents and incidents. Incident analysis identified learning opportunities, and this was shared with staff to support their learning and understanding.
Internal audits, checks, systems, and processes had been strengthened. Actions identified from monitoring procedures were added to an ongoing improvement plan. This supported the service to continually develop.
The management team were open and honest and had worked well at making the required improvements. The management team acknowledged further time was required for improvements to become fully embedded and sustained.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rated inspection for this service was inadequate (published 17 November 2022). Breaches in regulations relating to safety and governance were identified, and warning notices issued.
At this inspection, we found enough improvements had been made and the service was no longer in breach of regulation.
This service has been in Special Measures since the last inspection. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.
We looked at infection prevention and control 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 COVID-19 and other infection outbreaks effectively.
Please see the safe and well-led sections of this full report. You can read the report from our last inspection, by selecting the 'all reports' link for Cedar Court Residential and Nursing Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.