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Inspection carried out on 22 February 2018

During a routine inspection

Cedar House is registered to provide two regulated activities; accommodation for persons who require nursing or personal care and personal care. The service has a care home and also provides a domiciliary care service to people living in supported living schemes.

The care home was last inspected in December 2015; however, this was the first comprehensive inspection of the domiciliary care service.

We have written our report under the headings Care Home and Domiciliary Care Service to ensure that our specific findings for both services are clear.

Care Home

This inspection took place on 22 and 23 February 2018 and was unannounced.

Cedar House is a residential care home for six people with enduring mental health conditions, learning disabilities and complex healthcare needs. On the day of our inspection there were five people using the service.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service remained Good.

People told us that they felt safe living at Cedar House. Care staff demonstrated a clear understanding of what it meant to protect people and the steps they would take to keep people safe and free from harm.

Risk assessments identified people’s individual risks and provided detailed guidance for care staff on how to mitigate or minimise risk in order to keep people safe.

The provider followed robust recruitment processes to ensure that only care staff assessed as safe to work with vulnerable people were employed.

People received their medicines safely, on time and as prescribed. The provider had systems in place to ensure the safe management of medicines.

Accidents and incidents were recorded, monitored and analysed in order to support further learning and improvement.

Care staff received regular support and development through training supervision and annual appraisals in order to effectively carry out their role.

At the last inspection we found that some people using the service may have had their liberty restricted without the appropriate authorisations in place. At this inspection we found that this had been addressed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We observed kind and caring interactions between people and care staff, where people had built positive relationships with the care staff that supported them.

People and relatives knew who to speak with if they had a complaint or concern and were confident that their concerns would be dealt with appropriately.

Care plans were detailed and person centred and provided clear information about the person, their likes, dislikes, choices and preferences on how they wished to be supported.

Appropriate management oversight systems in place ensured that there was continuous monitoring of the care and support people received. Where issues or gaps were identified processes in place supported learning and improvement to allow the delivery of high quality care.

Further information is in the detailed findings below

Domiciliary Care Service

This inspection took place on 22 and 23 February 2018 and was unannounced.

This is the first comprehensive inspection of this service. Cedar House provides the regulated activity of personal care. This service provides care and support to people living in a number of ‘supported living’ settings, so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used f

Inspection carried out on 23 December 2015

During a routine inspection

We inspected the service on 23 December 2015. The inspection was unannounced. At our last inspection on 14 May 2014, the service met the regulations that were inspected.

Cedar House provides residential accommodation for up to six adults with continuing mental health problems. On the day of our inspection there were five people using the service.

At the time of our inspection there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People that we spoke with were positive about the service that they received and about the staff who supported them. We saw positive and friendly interactions between staff and people. Staff were aware of peoples individual needs and how they were to meet those needs.

People told us they felt safe and relatives also confirmed that they felt that their relative was safe living at the service. Procedures relating to safeguarding people from harm were in place. Staff received regular training in this area. The registered manager and staff understood how to protect people from abuse and knew what procedures to follow to report any concerns.

The manager and staff had sound knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, at the time of the inspection we found that some people had aspects of their freedom restricted. It was unclear in some cases as to whether appropriate applications had been made in full compliance with the DoLS and relevant requirements of the MCA 2005.

Care plans were person-centred and reflected individual’s needs and preferences. Consent to care was sought from the person using the service or their relative or advocate. However, the service had not completed their own mental capacity assessments where required and applications had not been submitted for people who may possibly have been deprived of their liberty.

There were systems and processes in place to protect people from the risk of harm. These included robust staff recruitment, staff training and risks assessments that considered the individual potential risk for each person using the service. However, on the day of the inspection we noted that there were no window restrictors in place in any of the rooms especially in bedrooms on the first floor. We told the registered manager about this who took immediate action to deal with this issue.

Staffing levels were determined based on level of need assessments which had been completed for each person living at the service. However, a recent visit by the local authority had recommended that the service make provision for an additional member of staff in the morning. The service had taken on board this recommendation and were in the process of recruiting an additional support worker.

Medicines were administered safely and staff had received appropriate training. The home had a clear policy on the administration of medicines which was accessible to all staff.

People were supported to eat and drink where appropriate. Staff supported people to attend healthcare appointments and ensured that people were supported to access the GP and other health professionals where required.

Staff had the appropriate skills and knowledge to carry out their role effectively. All staff received a comprehensive induction when they first started work with the service followed by regular training. All staff received regular supervisions and were given the opportunity to discuss strengths, their performance and any training needs. As all the staff at the service were relatively new, none had received an appraisal but the registered manager informed us that most staff will be completing one year over the coming months and so an appraisal would be scheduled appropriately.

The management team were accessible and approachable. People and their relatives knew who the manager was and felt able to speak with the manager if they had any concerns or issues. Staff also told us that the manager was approachable. A complaints policy was available and all complaints that the service had received were recorded within a complaints folder.

An incident folder was in place which recorded all incidents that had occurred within the home, the action that the service had taken and any learning that had taken place so that care practises could be improved upon where appropriate.

Monthly audits were carried out across various aspects of the service which included medicine administration audits, health and safety and compliance audits which covered several aspects of the overall management of the service. Where these audits identified improvements that were required, actions had been taken to make those improvements and these were recorded.

At this inspection there was one breach of Regulation 13 which was in relation to depriving someone of their liberty without lawful authority. Please refer to the ‘Effective’ section of this report for details. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 14 May 2014

During a routine inspection

A single inspector carried out this inspection. The focus of the inspection was to gather evidence to answer five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

During this inspection we spoke with three people who used the service and two relatives of people who used the service. We also spoke with the Registered Manager and three care staff.

Below is a summary of what we found. The summary describes what people using the Service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who used the service told us that they felt safe in the home. People said that they felt comfortable in the home and that members of staff treated them with respect and dignity.

Safeguarding procedures were comprehensive. When we discussed safeguarding with staff, they were aware of the signs of abuse and the action to take when responding to allegations or incidents of abuse. We looked at the safeguarding training records for three members of staff and noted that two members of staff required refresher safeguarding training according to the training certificates we were shown. The Registered Manager confirmed that they would attend a safeguarding refresher training course on 17 June 2014.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have been submitted, appropriate policies and procedures were in place.

We saw evidence that employment checks had been carried out to ensure that people were cared for by suitably qualified, skilled and experienced staff. We noted that in two files, references had been obtained but these were not stamped by the referee or verified by the employer. It was therefore not clear if these references were authentic.

The service had systems in place to identify assess and manage risks related to health, welfare and safety of people who used the service.

Is the service effective?

People told us that they were satisfied with the care they received at the home and felt that their needs had been met. One person who used the service told us "Staff are nice. They are helpful, respectful and polite�. Another person told us that the home was �good� and �I have no complaints�.

We looked at three care files and saw that people's care needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out where necessary. Care plans included information about people's preferred routines and healthcare needs. Relatives we spoke with told us that care files were always up to date and said that they were always available if they wanted to see their relative�s care plan.

We saw evidence that mental capacity assessments had been carried out where necessary with the involvement of healthcare professionals.

Staff told us that they were well supported by the Registered Manager and that there was good communication amongst staff. This enabled them to carry out their roles effectively, which in turn had an impact on the quality of care people received.

Is the service caring?

People who used the service and relatives were positive about the staff at the home. They told us that they had been treated with respect and dignity in the home. One relative told us �Every time staff are respectful and polite�. One person who used the service said "Staff are friendly and helpful". During our inspection, we saw that there was good interaction between staff and people who used the service.

People looked well cared for and we saw that the atmosphere was relaxed in the home.

Staff we spoke with said that they were aware that all people should be treated with respect and dignity and were able to give us examples to demonstrate how they ensured this.

Is the service responsive?

People who used the service and relatives we spoke with told us that if they had any concerns or complaints, they would feel comfortable raising them with staff or the Registered Manager.

We saw that the home had a complaints, suggestions and compliments policy and procedure. Complaints were documented and we saw evidence that the home had dealt with these accordingly.

We saw evidence that the service had carried out a survey in September 2013 asking people for their views about the home. They then analysed the information from the survey and looked at improvements that they could make to the home.

People's care and health progress was monitored closely. Written notes about people's health and care were completed by staff. People's care plans and their health needs were regularly reviewed with people who used the service.

Is the service well-led?

The home had quality assurance processes in place to help ensure that people received a good quality service. People who used the service told us that they felt listened to by members of staff and the Registered Manager.

Resident meetings were held monthly which enabled people to discuss issues regarding the running of the home. This encouraged people to raise queries and concerns with management and members of staff.

Staff told us that staff meetings took place monthly which aimed to enable staff to raise queries and concerns with their team and share information. All staff we spoke with told us that they felt able to consult the Registered Manager if they had concerns or queries and said that they felt supported.

Management in the home completed regular audits such as health and safety and premises risk audits.

Inspection carried out on 15 October 2013

During an inspection to make sure that the improvements required had been made

We carried out this inspection to check whether the provider had made improvements since we lasted visited on 10 May 2013. At that inspection we found that the registered manager did not have suitable arrangements in place for obtaining, and acting in accordance with the consent of service users who needed help with their money. At the inspection we found that people�s capacity had not been assessed in relation to managing their own money. At the inspection on the 15 October 2013, we found that the registered manager had arranged for capacity assessments and best interest meetings, under the Mental Capacity Act 2005. The decisions from the best interest meetings, were reflected in people's care plans and risk assessments.

We found that the registered manager had not protected people against the risk associated with the unsafe use and management of medication. We saw the manager did not check the medication administration record (MAR) sheet, before beginning to dispense medication or during. Therefore people may have been at risk of receiving, incorrect medication. At the inspection on 15 October 2013 we saw staff members checked the medication administration record (MAR) sheet, before, during and after administration of medication. We spoke with two people who lived at the home; both were able to say what medication they were on and why. One person said, �I know my medication, I know what it�s for and how many I�m taking."

At our last inspection 10 May 2013, we found that the registered manager failed to ensure that people using the service were protected against the risk associated with unsafe or unsuitable premises by means of adequate maintenance. At the inspection on the 10 May 2013, we found people�s bedrooms were in a poor state of repair, as was the kitchen, laundry room and sitting room. On our return the provider had re-furbished all the bedrooms, kitchen, laundry room and sitting room. We spoke with four people, one person said, �I went with staff to choose my bed, it�s really comfortable, it has a TV hidden in it�. Another said, �I choose the colour of the paint in my room, I now have a really comfortable bed."

Inspection carried out on 22 July 2013

During an inspection to make sure that the improvements required had been made

During our inspection on the 10 May 2013 we found non-compliance with meeting nutritional needs of the people who used the service. The provider submitted an action plan to address the areas of non-compliance.

At our inspection on the 22 July 2013 we found that, the manager had set in place procedures that would ensure staff were defrosting food correctly following the guidance from the Food Standards Agency. We saw that the home now had a separate fridge for defrosting meat. The night staff were required to check the contents of the fridge and freezer to ensure enough food was available for people for the following day. The staff were buying fresh fruit and vegetables along with bread, milk and other store cupboard essentials on a regular basis.

We spoke with four people who lived at the service; all four agreed more food was available for them. One person said "look in the fridge, look in the cupboards we have everything we need, when we need it." We spoke with two staff members both were aware of food safety issues and confirmed that regular shopping trips were taking place to buy fresh fruit and vegetables and other essentials. Food and safety training had taken place for staff where updated training was required. We saw the home was ensuring it always had a choice of suitable and nutritious food in sufficient quantities to meet people�s needs.

Inspection carried out on 10 May 2013

During a routine inspection

We saw each person had their own room. Staff stated they would knock three times before entering people's room. People agreed that this happened. One person said the staff "treat me with respect and call me by the name I like."

There was no evidence that people had been assessed and alternatives had been explored or a permission form had been signed to allow staff to look after peoples finances or review people's capacity to access if it had changed.

People�s needs were assessed and care and treatment was planned and delivered in line with their individual care plan, which included people's likes and dislikes.

We saw that the home did not have enough vegetable and basic supply's available for people to ensure they were provided with a nutritionally balanced diet and that they were placed at risk of contamination from poorly stored and prepared food.

We observed people receiving medication; however the manager did not check the medication record before beginning to dispense medication or during administration to people. The homes medication policy stated that "medication must be checked administered and signed for on the medication record by one person who is accountable for all stages of the medication." This was not happening in practice.

We spoke with three people who all felt there were enough staff available to meet their needs. One person said "staff treat me well, they see to all my wellbeing."