Cedardale Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not protected from known risks to their health and wellbeing. There was not sufficient guidance in place to inform staff how best to support people with the risks of falling, seizures, constipation and managing behaviour of distress. The environment was not always clean, in good condition, or suitable for people living with dementia. Although the registered manager recorded falls, learning was not always clear, and there was no clear process of sharing information with staff. Some incidents of abuse had not been identified and reported to the local authority safeguarding team. We found 3 breaches of the legal regulations in relation to safe care and treatment, safeguarding, and staffing.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. Some relatives told us they were not updated following incidents including when their loved ones had fallen. One relative told us that their relative had a UTI (urinary tract infection), and staff failed to update them about how this impacted their loved one’s health.

Lessons were not always learned from incidents or complaints, resulting in changes that improved care for others. For example, following a fall learning was not shared with the staff team to ensure they knew actions to take to reduce falls. Following a fall, the registered manager identified that staff should have been present in the lounge, but were not. There was no evidence this information was shared with staff to ensure staff were always present to support people. We observed periods of time where there were no staff present in the lounge during our assessment.

There was not a robust system in place to review and analyse incidents to ensure that appropriate action was taken to mitigate any known risks to people. Following each incident, the registered manager or deputy manager reviewed incident forms, and ensured that action was taken to seek any medical support for people. However, the registered manager did not review incidents or accidents for trends, triggers or causes. Some people were at risk of falling. When people fell, the registered manager took action to ensure they were seen by a medical professional. However, there was no oversight of falls, to review when the fall occurred, and the potential cause of the fall. There was no analysis of the staffing numbers on duty, or any other factors that could impact on people falling. The majority of falls between May 2024 and August 2024 were unwitnessed. There was no evidence the registered manager had reviewed and updated people’s care plans, or that actions were taken to mitigate the risk to the person.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. Some relatives told us they thought their loved ones were safe and happy living at Cedardale, however one relative told us their loved one’s jewellery had gone missing, and the registered manager had not investigated this.

Although staff told us they understood their responsibilities in relation to safeguarding, not all staff had completed safeguarding training. One staff member had been involved in a distressing incident, we asked, and they confirmed they had not completed safeguarding training before or following the incident. Another staff member told us they were confident to raise concerns if they needed to, but were not clear on how they would do this outside of the service.

Systems to protect people from the risk of abuse were in place but learning and outcomes were not always clear. When incidents of concern were identified, the registered manager mostly took action to report it to the local authority safeguarding team. However, outcomes of safeguarding and learning from incidents were not always clearly documented. During the assessment we identified 2 incidents which had not been reported to the local authority safeguarding team. There was one incident of unexplained bruising to a person. We discussed this with the registered manager, who advised they would review their processes. Following the assessment the registered manager contacted us to confirm they believed they found the cause of the bruising. There was also an incident where one person hit another person in the stomach with a cushion, the incident report noted that after the incident the person ‘held their stomach.’ This incident had not been reported to the local authority safeguarding team.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. One person had lost over 5kg in weight in a month. There was no information about weight loss in their care plan, and they had not been referred to the dietician, or been monitored more closely following their weight loss. We raised this with the deputy manager who completed a referral to the GP and told us they would fortify the person’s food.

Staff told us they understood risks to people, and knew how to support them safely, however we found this was not always the case. For example, one person was at risk of skin breakdown. Staff knowledge about how to support the person was limited. They told us the person could re-position themselves independently, however the care plan stated they needed staff support to do this. Staff told us the person’s pressure mattress was set to their weight; however, they did not know the persons weight, or how to check if it was set to the right weight which left the person at risk of significant harm.

Some people could become very distressed. One person had a number of incidents where they became distressed and were physically abusive to staff and another person at the service. There was not sufficient guidance in place to inform staff how best to support the person and de-escalate their distress. The registered manager had failed to review incidents of distress, and embed guidance to inform staff how best to support the person.

Processes were not always robust or in place to protect people from the risk of harm. Care plans and risk assessments for managing people’s known health and wellbeing needs were not always in place or sufficiently detailed to inform staff how best to support people. For example, one person was at risk of urinary tract infections (UTI), and had previously had UTIs. Their fluid charts showed their fluid intake was poor, however there was no risk assessment or care plan to inform staff how to mitigate the risk of UTIs for the person. There was no information to inform staff how to encourage the person with their fluid intake, and what actions to take if there were concerns about the persons fluid intake. Other risks to people’s health and wellbeing had not been risk assessed or mitigated. For example, one person had previously experienced seizures. There was no information within their care plan how the seizure could affect them, what a seizure looked like, and what action staff should take. Another person was at risk of high blood pressure, heart attack and a stroke. There was no risk assessments or guidance in their care plan to inform staff how best to support the person and mitigate any risks.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. The environment of the service was not dementia friendly; there was poor lighting in places with Velux windows creating pools of light along corridors. Handrails were not contrasting in corridors, which could cause confusion for people living with dementia. A toilet door was mirrored which was likely to prevent use as people may think a person was in the room. The décor of the service could confuse those with impaired vision which is common with dementia.

Staff shared with us frustrations about the service and the facilities. Staff told us that the bathroom was very cold, as there was no heat source, and that people did not receive the full benefit of the bath in place. Staff told us, “The Parker bath doesn’t tilt, they don’t get the experience.” Staff also shared frustrations about the internet within the service. Although they had raised concerns, and the provider had made some changes to the internet, it remained slow. This was particularly frustrating for them as it increased the time it took them to update care notes.

We observed people were not always safe at the service. One person’s bedroom window restrictor was not in place. We highlighted this to the deputy manager, who put the restrictor in place. We also observed that 2 cupboards storing a boiler and exposed pipes were unlocked and accessible to people, causing a risk to people who could become disorientated. One fire extinguisher was resting against the wall, and not securely attached to the wall. The stair lift service and check was out of date, and there was a note stating a quote needed to be sought. It was not clear if this was for repairs or the service. The registered manager could not explain why this had not been completed, as the stair lift check was due in January 2024.

The provider and registered manager failed to ensure that checks were effective and failed to identify shortfalls identified during this assessment. The registered manager had not identified that the window restrictor was not in place or how long this had been the case. There were no formalised checks to ensure pressure mattresses were set to the correct weight. Parts of the service needed updating, this had not been prioritised despite the registered manager telling us there was a service improvement plan in place.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. We received feedback from relatives and people that there were not enough staff. People told us, “Not enough staff, they are all leaving. The girls (staff) are rushing around and there is not enough staff,” and “Not enough staff, I have to wait for the one I want,” and “Staff don’t get time to sit and chat, Im quite sociable I do call them in but they don’t have time. I get lonely.” A relative told us they worry about the amount of staff as there are some occasions where some of the staff are called away to deal with other people and it feels that there are not enough on shift.

Staff induction was not sufficient to inform staff how best to support people. Staff told us that the induction for new staff “could be improved” and that staff were “thrown in the deep end.” Staff told us that they needed longer to get to know people, and understand each person’s needs. Staff told us, “They have 3 days training and then they are thrown into a shift.” Staff gave us mixed feedback about staffing levels. One staff told us, “Staffing wise is ok, they do try and put in a floater. We could do with a floater all day every day. It can be a push for the girls. Night staff do get people up, the double people.”

We observed staff attempt to be kind and caring towards people, however they lacked knowledge and skills in supporting people living with dementia. For example, we observed staff not knowing how to support someone who was asking to go home. Staff sometimes shouted towards people and spoke above where the person was positioned.

Processes to ensure that there were sufficient numbers of competent staff on duty were not always effective. Competency assessments had not always been completed. For example, one competency assessment stated that there was a ‘second major medication error’ and management noted that the staff member needed a further medication competency completed. Despite this being highlighted in March 2024, this had not been completed at the time of our assessment. Staff did not receive the support they needed in their roles. For example, some staff had been involved in distressing incidents, where they had been subject to physical violence from people. Following the distressing incidents, staff had not always had formal supervision, and when they did there was no mention of support needed following the incidents. Although rotas showed that there was the allocated number of staff on, some staff and relatives felt there were not sufficient numbers of staff on. Staffing was not reviewed following incidents of concern or falls to ensure that staffing levels were at the required level.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. People’s rooms were not clean and hygienic. One person’s room had faeces on their bedding, and on their dressing gown. This remained following the room being cleaned. We raised this with the registered manager and deputy manager, and they assured us the person’s belongings would be cleaned. One relative told us the service, “Looks clean, but smells bad some days.”

Staff told us that the service was clean, and that there were no malodours, however we found this was not the case. One staff member told us, “Not at all (malodours), the odd time, the cleaners are very good.” We spoke with the registered manager regarding the malodours within the service and they told us they appreciated the feedback. Staff told us they followed processes to ensure that infection control and prevention was followed. However, we observed there were 2 small shelves of medicines pots being stored in the sluice, which was not good infection prevention and control, and increased risks of preventable infections to people.

Throughout the service, including in people’s rooms, in hallways and within the entrance of the service, there was a strong smell of urine. Parts of the service were in a state of disrepair, and therefore they could not be sufficiently cleaned. For example, grouting was missing from around the bathroom floor which revealed grime. The toilet was thick with grime and limescale. The shelves in the bathrooms were warped from damp and degraded making them difficult to be cleaned. The upstairs bathroom had a rusted support frame; the rust marks stained the floor and would make it difficult to clean.

Processes to ensure that the service was clean, and without odour were not in place. We asked for audits of infection prevention and control and the deputy manager confirmed that none had been completed. Although the registered manager completed a regular ‘walk around’ of the service, issues we identified had not been identified and acted on, including strong odours, and parts of the service being in a poor state of repair.

While some of the people we spoke to expressed that they were generally happy with their care, our assessment found care did not always meet the expected standards. Most people told us they received their medicines as and when needed, we found this was not always the case. We found that people did not always receive their medicines when they were due, or with enough time before or after food. When people received ‘as and when’ medication staff had not documented if the medicine had the required effect and was effective.

Staff told us they had received training, and competency assessments to ensure they were safe to administer medicines. However, we found that after learning was identified within one staff members competency assessment, another was not completed when it was due. On the first day of our assessment, we observed staff completing the medicines round late into the morning. One person was administered their 7.00-8.00am medication at 10.25. Medicines were signed as being given between 7.00-8.00am. This increased the risk of people not having the gaps needed between medicine. On the second day of our assessment the deputy manager and the registered manager were both administering medicines; a task completed by one single staff the previous day. One of the morning medicines round had not started by 9.43, despite the fact that two staff members were completing the medicines round, instead of one.

Processes to ensure people received their medicines safely were not followed by staff. Staff were not always recording the exact placement of pain patches to ensure that the patch was rotated in line with the manufacture’s guidelines. Medication was not always administered at the time prescribed and in line with guidance. For example, one person was prescribed a medication at 7am, and to be taken an hour before food. Medicine administration records (MAR) were signed by staff as having been administered at 7am, however, we observed medicine being administered as late as 11am. This person had their breakfast at 9.30 every day. Staff could not be assured that the medicine was given an hour before food. Some people were at risk of constipation and were prescribed ‘as and when’ medicine to be given when they had not opened their bowels. One person did not have their bowel movements documented, and therefore staff could not be sure when the person last opened their bowels. On 3 occasions the person was administered ‘as and when’ medication without clear reasoning. We found that controlled medication was not always managed well. We reviewed controlled medicine and found records had not been kept up to date and medicine had not been signed in safely. One person was documented to have 5 pain patches in stock but should have had 6. Another person’s records stated they had 1 pain patch in stock, but they had 6.