Housing 21 – Cedar Court improved from Requires Improvement to Good across all five key questions, having remedied previous breaches in medicines management, staff training, governance and person-centred care. People reported feeling safe and well-supported, with positive feedback about kind, consistent staff and responsive, inclusive leadership.
Strengths
· Medicines management significantly improved since last inspection; MAR records accurate with no unexplained gaps and all staff trained and assessed as competent
· Risk management plans contained detailed, individualised guidance including SALT recommendations for people with swallowing difficulties
· Staff supported through regular supervision, appraisals, and competency checks including observed care delivery
· Cultural and diversity needs actively celebrated, including Black History Month and Diwali events involving people, relatives and staff
· Strong partnership working with health and social care professionals, with timely referrals when people's needs changed
Housing 21 – Cedar Court was rated Requires Improvement overall following an inspection in September 2019, with Safe rated Inadequate due to serious breaches in medicines management, insufficient staffing and flawed recruitment processes. The service received warning notices for Regulations 12 and 17, with further breaches of Regulations 9, 18 and 19, representing a deterioration from the previous inspection and continued failure to address longstanding concerns.
Concerns (11)
criticalMedication management: “seven people's Medicines Administration Record Charts (MARs) had gaps in them. These gaps were either unexplained or had stated the medicine was not in stock so they could not administer them.”
criticalStaffing levels: “a person told us that they had become unintendedly incontinent because two members of staff were not available to support them to go to the toilet when they needed this level of support.”
criticalStaff competency: “three newly employed members of staff had not fully completed their medicines training or medicine competency assessments since their employment began in November 2018, March and April 2019.”
criticalGovernance: “the internal audit did not identify and manage the concerns we found to improve the service. There was an action plan attached to the audit, however the recommendations had not all been implemented.”
moderateStaff training: “13 members of staff including the housing and care manager staff that had expired training in basic life support and safeguarding of vulnerable adults.”
moderateIncident learning: “the housing and care manager recorded all incidents that occurred at the service, however there was no detail of learning from those incidents that occurred or the actions taken to improve the service.”
moderateCare planning: “a person's risk assessment had not been updated when a change in transfer equipment was suggested following an occupational therapist's assessment.”
moderateLeadership: “Staff did not feel comfortable to raise their concerns because they felt insufficient action would be taken. 'There is a lack of management support and only when things go wrong the manager tells you off'”
moderateRecord keeping: “Pre-employment checks were not routinely collected before staff began to work at the service. We found inconsistencies in three staff records one application form was missing.”
moderatePerson-centred care: “The provider had not ensured the service was fully meeting the AIS. People's care assessments recorded they had specialist communication needs... however, care records did not provide sufficient information.”
minorCultural competency: “People's cultural heritage and religious beliefs were recorded, but there was no evidence that the provider took any action to meet people's individual needs.”
Strengths
· People felt safe and staff had a clear understanding of safeguarding responsibilities and how to report abuse promptly.
· People and relatives were involved in assessments and care reviews; staff described as kind, caring and compassionate.
· People's nutritional needs were met with meal support and access to an on-site daycentre.
· Staff had supervision and appraisals in line with provider recommendations.
· Service operated within principles of the Mental Capacity Act; consent processes were in place.
Quality-Statement breakdown (23)
safe: Using medicines safelyInadequate
safe: Staffing and recruitmentInadequate
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Learning lessons when things go wrongRequires improvement
safe: Preventing and controlling infectionRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
effective: Staff support: induction, training, skills and experienceRequires improvement
effective: Assessing people's needs and choices; delivering care in line with standardsGood
This focused inspection of Housing & Care 21 - Cedar Court found two regulatory breaches: insufficient staffing levels (Regulation 18) leaving people waiting unacceptably long for care, and unsafe care and treatment (Regulation 12) including inadequate risk assessment updates and an unsafe manual handling incident. Leadership was undermined by the absence of a registered manager, a culture of staff distrust, and inconsistent audit oversight.
Concerns (7)
criticalStaffing levels: “One night I had to wait for four hours as I am not allowed to get out of the chair. I'm not safe, I'll fall”
criticalStaffing levels: “The provider had not ensured there were sufficient staff to meet people's needs safely. These issues were a breach of Regulation 18”
criticalCare planning: “The care plan did not reflect changes in the person's needs. The person's falls risk assessment did not indicate options available when staff did not have a hoist”
criticalGovernance: “The lack of a registered manager and changes in management affected the monitoring and follow up on staff training, effective supervision and learning from incidents”
moderateLeadership: “There was a culture of distrust between staff and/or management. Staff told us they knew how to challenge practices but some were not confident that they would be listened to”
moderateIncident learning: “Staff spoken to were not aware of some incidents that had happened at the service...we did not see any evidence of how the team benefitted from any learning from incidents”
minorRecord keeping: “Checks were not sufficiently robust...audits had not picked up that staff had not ensured the person signed as stated in the policy and procedures”
Strengths
· Staff understood safeguarding procedures and knew how to recognise and report abuse
· People were supported to take their medicines, with errors identified, resolved and staff retrained
· Safe recruitment procedures including DBS checks, references and probationary periods were in place
· Personal Emergency Evacuation Plans (PEEPs) were in place for all people
· Staff followed good infection control and prevention practices including PPE and handwashing
Housing 21 – Cedar Court was rated Requires Improvement overall following a focused inspection of the Safe and Well-led key questions, with three regulatory breaches identified covering unsafe medicines management (Reg 12), poor governance and inaccurate records (Reg 17), and failure to deliver person-centred care (Reg 9). Strengths included safe staffing levels, robust safeguarding knowledge, strong infection control practices, and effective partnership working.
Concerns (5)
criticalMedication management: “Medicines were not always managed in a safe way to meet people's individual needs...staff did not apply the cream...risk of the person's health condition deteriorating”
criticalRecord keeping: “Medicine administration records (MARs) were not always completed accurately...the medicines audit did not find the concerns we found regarding the medicines that were not administered.”
criticalGovernance: “Provider's quality assurance and monitoring systems were not always effectively implemented...Audits had not identified these failures and therefore the manager had not taken action.”
criticalPerson-centred care: “A relative told us that care workers only completed tasks that were scheduled...soiled bedding that needed to be washed...refused by staff because the person was not scheduled to have their laundry completed.”
minorCommunication with families: “Contact details for people and relatives were incorrect despite requesting updated details.”
Strengths
· Staff were knowledgeable in safeguarding procedures and understood how to report concerns about abuse and risk of harm.
· Enough staff were available to support people; staffing levels were determined based on individual care needs.
· Robust recruitment process with pre-employment checks including DBS, references and right-to-work verification.
· Comprehensive risk assessments were in place and regularly reviewed, covering falls, mobility, medicines and nutritional needs.
· Infection prevention and control measures were fully assured, including PPE use, testing, shielding and visitor management.
safe:Insufficient evidence to rateeffective:Not ratedcaring:Insufficient evidence to rateresponsive:Not ratedwell-led:Insufficient evidence to rate
This targeted inspection of Housing 21 – Cedar Court (extra care, 35 people) confirmed that Warning Notices under Regulation 12 and Regulation 17 had been met, with improvements in medicines management, financial safeguarding, compassionate care, and governance. No ratings were changed as the inspection did not assess all areas of the key questions; the overall service rating remains Requires Improvement from the previous inspection.
Strengths
· Medicines management systems improved: sufficient stocks, accurate records, and safe administration following Warning Notice remediation.
· New financial abuse safeguards introduced, with weekly senior audits and manager oversight of residents' money records.
· Staff treated people with compassion and respect; people and relatives gave consistently positive feedback about care workers.
· Registered manager improved communication, transparency, and quality assurance processes, praised by staff and an external social care professional.
· Provider met requirements of Warning Notices related to Regulation 12 and Regulation 17; no longer in breach of regulations.
Housing 21 – Cedar Court was rated Requires Improvement overall following a focused inspection in February–March 2020, with Safe rated Inadequate due to continued breaches of Regulation 12 involving unsafe medicines management and financial safeguarding risks. Governance failures persisted under Regulation 17, with ineffective audits and absent registered management, while staff dignity and person-centred care breaches under Regulation 9 remained unresolved from prior inspections.
Concerns (15)
criticalMedication management: “One person's MAR had 14 medicines listed, but no staff signature for seven of them during four weeks in January 2020.”
criticalMedication management: “The MAR did not record the current dose of the medicine to be administered. This is critical information for staff because Warfarin doses are dependent upon the blood test results.”
criticalMedication management: “One person had run out of their medicines that helped to reduce the risks of choking due to a medical condition and this was not re-ordered.”
criticalSafeguarding: “Three people gave staff money to complete shopping for them. On each occasion the till receipts did not match the information that was recorded on the provider's financial transaction form.”
criticalGovernance: “These audits had not identified the issues we found in some of these MARs.”
criticalGovernance: “There was no overall ownership, oversight or clear leadership at the service. The previous registered manager was no longer employed at the service.”
moderatePerson-centred care: “What I don't like is when they shout. They think I'm deaf and I want them to listen to what I've got to say instead of shouting me down.”
moderatePerson-centred care: “I want to go toilet they say it's not your time yet and I've asked how long have I got to wait.”
moderateStaff competency: “The critical information regarding their competency to support people with their medicines unsupervised was not commented upon. Neither of the three competency assessments were signed or dated.”
moderateRecord keeping: “The provider failed to ensure audits were completed accurately and failed to maintain accurate records for all people using the service.”
moderateCare planning: “Staff did not always use people's information to provide them with appropriate care to meet their individual needs.”
moderateIncident learning: “Two people had consistently declined to take their medicines. This pattern of refusing medicines was not identified by staff and they had not supported the person to seek medical advice.”
moderateMissed or late visits: “Sometimes I don't have a carer, they don't turn up and they don't say they not coming.”
moderateLeadership: “Senior managers were reactive to the concerns we found rather than having insight to the service and acting proactively.”
moderateConsent / capacity: “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.”
Strengths
· Staff followed infection control processes; sufficient PPE supplies including gloves and aprons were available.
· Robust recruitment process with pre-employment checks including DBS, references and right to work verification.
· Staff morale and confidence had improved following interim management support; staff reported positive culture change.
· Accidents and incidents were monitored to identify trends and patterns for learning.
· Staff worked in partnership with local authority safeguarding, care commissioning teams and clinical commissioning groups.
Quality-Statement breakdown (13)
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Staffing and recruitmentRequires improvement
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in making decisions about their careRequires improvement
caring: Respecting and promoting people's privacy, dignity and independence
Housing & Care 21 – Cedar Court received an overall Good rating across all five key questions at its December 2016 inspection, demonstrating safe medicine management, robust recruitment, person-centred care and effective multi-agency working. The only noted concern was that the newly appointed manager had not yet registered with CQC, creating minor leadership uncertainty during the transition period.
Concerns (2)
minorGovernance: “The manager in post was new and had not yet registered with CQC as the registered manager.”
minorLeadership: “The recent change in manager had created some uncertainty as they were not sure what a new manager brings.”
Strengths
· Medicines were handled and administered safely with accurate MAR records and regular management checks.
· Robust recruitment procedures including references, DBS checks and right-to-work verification.
· Comprehensive staff induction, supervision, appraisal and training including MCA, safeguarding and moving and handling.
· People felt safe and staff were knowledgeable in recognising and reporting signs of abuse.
· Care plans were person-centred, regularly reviewed and reflected individual preferences including gender of carer.
effective: Staff working with other agencies; supporting people to live healthier livesGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityRequires improvement
caring: Supporting people to express their views and be involved in decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Meeting people's communication needsRequires improvement
responsive: Planning personalised care to meet people's needs, preferences and interestsRequires improvement
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Promoting a positive, open, inclusive and empowering cultureRequires improvement
well-led: Managers and staff being clear about roles; continuous learning and improving careRequires improvement
well-led: Engaging and involving people and staff; considering equality characteristicsRequires improvement
well-led: How the provider understands and acts on the duty of candourGood
well-led: Working in partnership with othersGood
Requires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staffRequires improvement
well-led: Continuous learning and improving careRequires improvement