Archived: The Cedars Nursing Home

The Cedars Nursing Home is a purpose-built care home registered to provide personal and nursing care for to up to 31 people. The home is situated in the town of Shaftesbury, Dorset. At the time of our inspection there were 27 people using the service.

People’s experience of using this service and what we found.

The Cedars Nursing Home was a safe service. Policies and procedures in place ensured the home operated consistently and people told us they felt happy and secure. There were enough staff on duty who had been recruited through a robust process. Staff received a thorough induction to the home, and this included agency and bank staff. Clinical skills and processes were under continual review. Staff understood their responsibilities to safeguard people from harm and abuse and processes showed the correct processes had been followed to highlight concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People received their medicines as prescribed and people’s more complex nursing needs were managed well, such as, wound care and long-term medical conditions. The home had good working relationships and clear channels of referral to a variety of health and social care professionals.

Risks to people’s health and wellbeing were assessed thoroughly and clear instructions meant staff were working in safe ways. People were protected from avoidable infections as the home was clean and staff had good hygiene practices. Accidents and incidents were recorded and used to identify lessons learned, these were shared with the staff team.

Governance and leadership was strong within the home. Continual monitoring and improvement through audits took place to ensure the home operated effectively and people were safe. Staff were proud to work at The Cedars Nursing Home and were positive about the management of the home. People told us they felt part of the home, their views mattered, and regular surveys ensured changes were implemented.

The registered manager understood their statutory requirements and all notifications had been made to CQC as required by law. The registered manager told us to work in an open and transparent way was important to them.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 July 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has remained at good 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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Cedars Nursing Home is a large detached property in Shaftesbury. The home provides long term accommodation for up to 31 older people with personal care and nursing care needs. At the time of our inspection 26 people were living at the home.

People’s experience of using this service and what we found

Quality monitoring systems had improved since the previous inspection. Improvement actions were identified promptly and measures put in place to prevent a reoccurrence.

People felt safe and were protected from avoidable harm as staff had been trained to recognise signs of abuse and knew who to report this to if they had concerns.

People had personalised risk assessments and staff understood the actions required to help minimise these risks. This included close monitoring of food and fluid intake for people at risk of malnutrition and dehydration. Effective staff communication meant concerns about people’s intake were handed over and escalated as required.

Medicines were managed safely. A system had been introduced since the previous inspection to record time critical medicines. People told us they received their medicines on time. Staff had received the relevant training and competency checks.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The home was recording mental capacity assessments and best interest decisions in line with the Mental Capacity Act 2005 (MCA).

Staff sought timely advice from health care professionals when people showed signs of being unwell. The home understood the importance of good daily oral health care and supported people to access dental services.

People had the opportunity to participate in a range of activities and were consulted monthly about the activities programme. When people wished to spend time alone this was respected.

Assessments and care plans were detailed and included involvement from people and, where appropriate, their relatives and health and social care professionals.

The home worked closely with other agencies including GP surgeries and the local authority to ensure people’s health and wellbeing was maintained and to prevent any unnecessary hospital admissions.

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 rating for this service was requires improvement (published 05 July 2018) and there were two breaches of regulation. Since July 2018 the provider had sent in monthly reports to CQC which demonstrated more robust auditing and improvements in medicines management, pressure care, falls, nutrition and hydration and the accuracy and completeness of people’s care records. At this inspection we found further evidence to confirm improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Cedars Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Cedars Nursing Home is a large detached property in Shaftesbury. The home provides long term accommodation for up to 31 older people with personal care and nursing care needs. At the time of our inspection 27 people were living at the home.

The service had 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.

Safe care and treatment was not always being delivered at The Cedars nursing Home. Medicines were not always stored and administered safely. Times of time critical medicines were not recorded which meant that the nursing staff administering medicines could not always be sure that medicines were administered consistently with the appropriate time gaps between doses. Safety needles in line with the Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 were not being used by clinical staff within the home. A medicine capsule was found in a person’s care file and pressure relieving mattresses were not always set at the correct setting. Risks had not always been assessed for everyone who was living in the home and catheter care procedures were not in place.

Mental Capacity Act records were not completed accurately and there were areas of care and equipment which had not been assessed or best interest decisions recorded in line with the Mental Capacity Act 2005 (MCA). These included the use of tilt and space chairs for people which restricted movement and the administration of medicines prescribed as required (PRN).

We reviewed the current audit processes The Cedars Nursing Home were using and found that the audits continued to be ineffective and inaccurately completed since our last inspection. For example, care plan audits did not cover capacity assessments or best interest decisions. This meant that gaps we found were not identified or actions taken to improve these in line with the MCA. Records and audits had not been completed accurately for example mattress audits had ticks in the wrong boxes and personal care charts had not recorded oral care for the past three months.

People, relatives, health professionals and staff told us that The Cedars Nursing Home was a safe home. Safeguarding alerts were being managed and lessons learnt by the home. Staff were able to tell us how they would report and recognise signs of abuse and had received training in safeguarding.

There were sufficient numbers of safely recruited staff at the home. A dependency tool was used to calculate the number of staff hours required to meet people’s needs.

Care plans were in place which detailed the care and support people needed to remain safe whilst having control and making choices about their lives. Most people had a care plan and associated files which included guidelines to make sure staff supported people in a way they preferred. Staff had access to people’s care plans and daily records.

Staff had a good knowledge of people’s support needs and received regular local mandatory training. They also received training in response to people’s changing needs for example dementia care.

Staff told us they received regular supervisions which were carried out by the management team. Staff told us that they found these useful. We reviewed records which confirmed this. People and relatives told us that the food was good. We reviewed the menu which showed that people were offered a variety of healthy meals. People were supported to access healthcare appointments as and when required and staff followed professional’s advice when supporting people with ongoing care needs. Records we reviewed showed that people had recently seen the GP, district nurses and a chiropodist.

People, professionals and relatives told us that staff were caring. We observed positive interactions between staff, managers and people. This showed us that people felt comfortable with the staff supporting them. Staff treated people in a dignified manner. Staff had a good understanding of people’s likes, dislikes and interests. This meant that people were supported by staff who knew them well.

People had their care and support needs assessed before being admitted to the service and care packages reflected needs identified in these. We saw that these were regularly reviewed by the service with people, families and health professionals when available. People were encouraged to feedback. There was an active system in place for recording complaints which captured the detail and evidenced steps taken to address them. The registered manager told us that lessons were learnt and shared with staff in meetings. This demonstrated that the service was open to people’s comments and acted promptly when concerns were raised.

Staff had a good understanding of their roles and responsibilities. Information was shared with staff so that they had a good understanding of what was expected from them. Staff felt recognised and that team moral was good. People, relatives, professionals and staff felt that the service was well led. The registered manager encouraged an open working environment. The service understood its reporting responsibilities to CQC and other regulatory bodies and provided information in a timely way. The service worked in partnership with other agencies. Professionals told us that communication with the home was good.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The Cedars Nursing Home provides accommodation for up to 31 people. It delivers palliative and end of life care to older people, including people with dementia type illnesses. There were 31 people living in the home at the time of the inspection. The home was split across two floors. On the ground floor there were 15 bedrooms three of which were en-suite and on the first floor there were 16 bedrooms two of which were en-suite

The service had a registered manager in place. 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.

Quality monitoring systems used at The Cedars Nursing Home were not effective and did not give the auditor space to write comments or record actions to be taken. We found gaps in recording which had not been picked up during quality checks.

The service did not display their rating from the previous inspection on their website. On day two of the inspection this had been rectified.

Medicines were not always managed safely. We found one person who had recently been admitted had gone nine days without one of their medicines. A GP was called and recorded that the person had not suffered any adverse effects as a result of this. Medicine Administration Charts (MAR) were not always accurately completed.

People’s capacity was assessed and best interest decisions were recorded however, records only evidenced that the acting manager had been involved in the decision making which meant that decisions made might not always be the least restrictive or in the person’s best interest. We were told that these would all be re-reviewed and that families and professionals would be involved.

People, relatives, health professionals and staff told us that the service was safe. Staff were able to tell us how they would report and recognise signs of abuse and told us they had received safeguarding training. We reviewed the training records which confirmed this.

Care plans were in place which detailed the care and support people needed to remain safe whilst having control and making choices about how they lived their lives. Each person had a care file which also included guidelines to make sure staff supported people in a way they preferred. Risk assessments were completed, regularly reviewed and up to date.

Staff had a good knowledge of people’s support needs and received regular mandatory training as well as training specific to their roles.

Staff told us they received regular supervisions which were carried out by management. We reviewed records which confirmed this. Staff told us they found these useful.

People were supported to maintain healthy balanced diets. Food was home cooked using fresh ingredients and people said that they enjoyed it. Food options reflected people’s likes, dislikes and dietary requirements.

People were supported to access healthcare appointments as and when required and staff followed GP and District Nurses advice when supporting people with on-going care needs.

People told us that staff were caring. We observed positive interactions between staff and people throughout the inspection. This showed us that people felt comfortable with staff supporting them.

Staff treated people in a dignified manner. Staff had a good understanding of people’s likes, dislikes, interests and communication needs. Information was available to people. This meant that people were supported by staff who knew them well.

People were supported with end of life care. The registered manager told us that the home had been awarded a beacon status for the Gold Standards Framework (GSF) for past five years. The Gold Standards Framework is a programme care homes use to improve end-of-life care by offering staff training and a framework to help identify, assess and deliver good care.

People had their care and support needs assessed before using the service and care packages reflected needs identified. We saw that these were regularly reviewed by the service with families and health professionals when available.

There was system in place for recording complaints which captured the detail and evidenced steps taken to address them. People and relatives told us that that they felt able to raise concerns or complaints and felt that these would be acted upon. This demonstrated that the service was open to people’s comments and acted promptly when concerns were raised.

People and staff felt that the service was well led by the registered manager. The registered manager and others in the management team all encouraged an open working environment. All the management had good relationships with people and all worked shifts with staff.

The Cedars Nursing Home provides nursing, personal care and accommodation for up to 31 people. There were 30 people living there at the time of our visit some of whom were living with dementia or other mental health conditions.

There was a registered manager. 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.

There was a system for assessing people’s level of dependency in order to calculate the correct numbers of staff needed to provide the right level of care for people. The systems manager told us that the staff rostered for the day of our inspection was correct based on people’s assessed needs. However staff and healthcare professionals told us there was not always sufficient staff to meet people’s needs.

There had been staff changes and new staff had been recruited. There was some use of agency staff to cover gaps in the duty roster. The registered manager told us they had recruited two activity staff so that care workers would remain on the roster to provide care for people. Staff told us that during our inspection some people had a delay in receiving personal care.

People’s risks were assessed and care plans developed to minimises their risks. One person, who was at high risk of skin damage because of a medical condition, developed a wound. The person was referred to the tissue viability team and their care plan was reviewed. Their care plan was updated as necessary.

Some people remained in their rooms to have their meal and some people stayed in the lounge. Most of the people who stayed in the lounge were sat in an armchair with a small table in front of them. The meal time was not a social experience for people. We saw staff standing when supporting some people with their lunch and one person was asleep with their meal in front of them. Another person who was in their room alone had their pudding in front of them untouched an hour later.

People had personalised care plans which included their likes and dislikes however this was not always reflected in the care people received. One person’s care plan stated they liked to go to the lounge. We saw they had gone to the lounge four times in one fortnight period. We spoke with staff about this they told us the person sometimes got agitated in the lounge however their records did not demonstrate if the person had been offered a choice.

There was an activity calendar which included room visits each day. They were for people who were unable to attend the lounge. Staff completed a room visits diary however we saw there were some gaps and staff were unclear if room visits had taken place on those days. There were a variety of activities which people could participate in, these included quizzes, exercise to music and poetry. On the day of our inspection there was a fitness instructor who provided exercise to music for an hour in the afternoon.

There were systems for monitoring the quality of the service. When there was a quality check which identified the service was not meeting an acceptable standard, actions were taken. We identified some gaps in recording in peoples fluid charts and charts to record if people had their cream applied, the quality checks had identified these gaps and the deputy manager was able to tell us what actions they had taken to make improvements.

People were treated with respect and their privacy was maintained. Staff responded positively to people and used appropriate non-verbal communication skills to demonstrate they were listening and attentive to people.

Concerns and complaints were managed appropriately. There was a complaints policy and we saw complaints were resolved within the times specified.

The service maintained links with the community, such as they held regular coffee mornings and a twice yearly friends and family forum.

All of the people we spoke with told us that staff did everything they needed them to do for them. One person told us that the staff, 'know me, know my ways. I appreciate that.' Another person told us that the staff were, 'very kind.' One person's relative told us that their relative was always well looked after and that they could not fault the care. People's needs were assessed and care was planned and delivered to meet their needs.

Staff were trained to deliver appropriate care and treatment. Staff told us that they felt supported and they received supervision and appraisals.

People were protected from the risks of unsafe care or treatment because the home held an accurate record of people's needs.

One person told us that staff were 'Extremely helpful' and one person's relative told us 'The home is fantastic.' People were not always able to summon assistance, and care plans did not always reflect people's needs.

The provider carried out sufficient pre employment checks and people were cared for, or supported by, suitably qualified, skilled and experienced staff.

Records were not always accurate or kept securely.