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Inspection carried out on 22 May 2018

During a routine inspection

Cedar Grange is a care home which offers nursing care and support for up to 60 predominantly older people. At the time of the inspection there were 52 people living at the service. Some of these people were living with dementia. The service occupies a large purpose built detached house over two floors. The service is divided in to four separate units.

This unannounced comprehensive inspection took place on 22 May 2018. The last comprehensive inspection took place on the 14 and 17 March 2017 when the service was not meeting the legal requirements. The service was rated as Requires Improvement at that time. People's safety was not always protected. We identified issues in the recording and management of risks to some people. People who were vulnerable due to not being physically mobile, were not protected against the risk of other people entering their bedrooms and engaging in activities which were harmful. We took enforcement action against the service due to the concerns found at that inspection. We returned to carry out a focused inspection on 9 August 2017 to check on the action taken by the provider to meet the requirements of the regulations. At the focused inspection we found the service had made improvements and was no longer in breach of the regulations. However, the service rating of Requires Improvement was not changed at that inspection, as we required to see that changes were sustained over time. At this comprehensive inspection we found the service had sustained the changes made and had continued to make further improvements. The service is now rated as Good.

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 service is required to have a registered manager and at the time of the 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 and associated Regulations about how the service is run.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes.

The premises were well maintained. The service was registered for dementia care. There was little pictorial signage at the service to support people who were living at the service with dementia, who may require additional support with recognising their surroundings. The décor of three of the units did not identify places easily for people. We have made a recommendation about this in the Effective section of the report.

The premises were regularly checked and maintained by the provider. Equipment and services used at Cedar Grange were regularly checked by competent people to ensure they were safe to use.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible.

The service had identified the minimum number of staff required to meet people’s needs and these were being met. The service had a number of staff vacancies at the time of this inspection and these posts were being filled by agency staff. The service was facing challenges in recruiting new staff. We were told this was due to businesses in the local ar

Inspection carried out on 9 August 2017

During an inspection looking at part of the service

Cedar Grange is a purpose built home and provides care for up to 60 elderly people who need care by reason of old age, dementia, mental disorder, and physical disability. The home also provides nursing care. The building is split into four units or suites as they are known, each accommodating up to 15 people. At the time of the inspection, there were 49 people living at the service.

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.

This unannounced focused inspection took place on 9 August 2017. The last comprehensive inspection took place on 14 and 17 March 2017. We identified breaches of the regulations at that inspection. The breaches related to the recording and management of risk, the management of medicines, lack of effective quality assurance processes and the poor compliance with the Mental Capacity Act (MCA). A warning notice was issued regarding the management of medicines and the recording and management of risk. Statutory requirements were issued for the other breaches of the regulations. The provider sent the Care Quality Commission an action plan detailing how the service would meet the requirements of the regulations. We carried out this focused inspection to check on the action taken by the service to meet the requirements of the warning notice. The action taken to address the requirements was also checked.

This report only covers our findings in relation to “Is the service Safe”; “Is the service effective” and “Is the service well led”. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cedar Grange Nursing Home on our website at www.cqc.org.uk.

At this inspection we found that action had been taken to address the concerns in the warning notice about the management and recording of risk and the safe management of medicines. We looked around the premises and found that the atmosphere had improved. People seemed calm and content. The doors to the downstairs units had been closed, meaning that people could no longer independently move between the two units. Some people had moved to different units, depending on their level of risk and need. There were new personal safety checks in place, so that people who were unable to independently use call bells were monitored every hour to help ensure they were safe. Locked water dispensers replaced the kettles in the kitchenettes, reducing the risk of people scalding themselves. We found one example where a risk assessment was not effectively implemented. The provider took immediate action to address this. We have made a recommendation about this in the report.

During this inspection we checked the services medicines systems. The management of medicines at Cedar Grange had improved and action had been taken to meet the requirements of the warning notice. At the last inspection, we found several medicines errors. These errors had not been reported as incidents and were not highlighted on the service’s medicines audit. This meant that learning from these errors might have been missed. At this inspection, we found that all errors were recorded as required.

During this inspection we reviewed the requirement notices in relation to compliance with the Mental Capacity Act. We found improvements had been made. Practices around covert medicines (medicines disguised in food or drink) had improved and there were clear best interest processes in place to ensure people’s rights were protected. The recording of consent had also improved, and we no longer found examples of people’s relatives consenting to their care without the correct legal authority to do so, such as a Lasting Power of Attorney (LPA).

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Inspection carried out on 14 March 2017

During a routine inspection

This inspection took place on 14 and 17 March 2017 and was unannounced.

Cedar Grange provides care for up to 60 elderly people who require support due to old age, dementia, mental disorder, and physical disability. The home also provides nursing care. The building is split into four units or suites as they are known, each accommodating up to 15 people.

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’s safety was not always protected. We identified issues in the recording and management of risks to some people. People who were vulnerable due to not being physically mobile, were not protected against the risk of other people entering their bedrooms and engaging in activities which were harmful. People did not always have call bells within reach and the stairgates intended to provide a barrier to people accessing bedrooms could be opened by some people living at the home.

People had risk assessments in their records, however these were not always reflective of the care being provided. There was an inconsistent approach to the recording of people’s resuscitation wishes, meaning that their treatment may not be provided in the way they wished, or might be delayed in the event of an emergency.

People’s medicines were not always managed safely. We found a range of errors on people’s medicines administration records (MAR). These had not been recorded on the computerised system as required. Although medicines audits were taking place, the frequency of these had been reduced from weekly to monthly, meaning that some incidents were not quickly identified. We found an excess of some medicines, expired medicines and medicines which had been opened without having the date of opening recorded.

Some people were prescribed medicine covertly; this means it was crushed in their drink or food. We saw that this had been agreed in consultation with the person’s doctor and this agreement was kept in their records. However, we saw little evidence of best interest processes to consider less restrictive alternatives to this practice. In addition, we saw that consent was not recorded appropriately in relation to people’s medicines, with relatives signing to give consent without the correct legal authority to do so.

There were systems in place to monitor the quality of the service at Cedar Grange, however these systems had not identified the issues we found during the inspection in relation to the management of medicines or the administration of covert medicines. In addition, the issues with the recording of consent and resuscitation wishes had not been identified. This meant that these systems were not always fully effective.

People and their relatives told us the service was safe. Staff had undergone training in safeguarding adults and knew what action to take should they witness a person being mistreated, including which external agencies they should alert. People were supported by staff who had been safely recruited. For example, they had undergone checks prior to commencing their employment to ensure they were suitable to care for people who were vulnerable. Although we observed suitable levels of care staff during the inspection, we were told that nursing staff felt under pressure at times and were often interrupted during their nursing duties, including medication rounds. We saw an example of one person missing their medication because the medication rounds had taken too long, meaning their doses were too close together.

People and relatives told us the service was caring. Comments from relatives included; “The staff show they care, they are so tender” and “They get the best out of my mum.” We observed kind

Inspection carried out on 1 September 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 6 May 2015. After that inspection we received concerns in relation to how people’s behavioural needs were being managed by staff, the recording of these incidents and whether this information was being passed to the local authority safeguarding team to investigate; people not being supported at appropriate times because call bells were not in reach and there were insufficient staffing levels; and the cleanliness of the environment. As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cedar Grange on our website at www.cqc.org.uk.

Cedar Grange is a nursing home providing care and accommodation for up to 60 older people, some of whom are living with dementia and may have mental health needs. On the day of the inspection there were 60 people living at the home. Cedar Grange is part of Cornwall Care Limited.

The service has four separate units to cater for people’s needs. The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

We visited in the evening between the hours of 6pm and 10.30pm and observed people having supper and looking happy and relaxed with the staff. People and relatives were happy with the care staff provided. One person said; “No grumbles.”

People’s care records held information about how people wished to be supported. Records were regularly updated to reflect people’s behavioural needs. However we found details of an incident that should have been passed to Cornwall safeguarding team. The information documented was found to have inconsistencies in the dates, times and details, and there had been no investigation by the registered manager to help ensure people remained safe.

People were observed to have call bells within reach and staff were observed attending to people when assistance was required. The senior nurse and staff on duty confirmed staffing levels were below normal during our visit. However neither felt this had an impact on the care provided.

People were in a service that was clean and well maintained.

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

Inspection carried out on To Be Confirmed

During a routine inspection

The inspection took place on 6 and 15 May 2015 and was unannounced. Cedar Grange is a nursing home providing care and accommodation for up to 60 older people, some of whom are living with dementia and may have mental health needs. On the day of the inspection there were 59 people living at the home. Cedar Grange is part of Cornwall Care Limited. The service has four separate units to cater for people’s needs.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

We observed people and staff chatting and enjoying each other’s company in a relaxed and calm atmosphere. Comments included; “I love it here.” People told us they were happy living there.

People and relatives were happy with the care and staff provided. Professionals and relatives said staff were competent and knowledgeable about the people they cared for.

People were supported and encouraged as much as possible to make everyday decisions and choices about their lives. Staff supported people with patience and understanding while protecting people’s privacy and dignity.

People were protected by safe recruitment procedures. Staff received a full induction and were supported with ongoing training to develop and maintain their skills. Staff competency was assessed and monitored. Staff, relatives and people said they felt there were sufficient staff on duty. Staff confirmed they had sufficient time to support people and did not feel rushed. A relative said; “Couldn’t wish for anything better.”

People had access to healthcare professionals to make sure they received appropriate care and treatment to meet their health care needs, such as GPs and dementia liaison nurses. Staff followed guidance provided by professionals to help ensure people received the care they needed to remain safe. For example, some people received one to one staff support to help keep them safe.

People’s medicines were managed safely. Medicines were managed, stored and disposed of safely. Nurses administered all medicines and had been appropriately trained and confirmed they understood the importance of safe administration and management of medicines.

The registered manager had sought and acted on advice where they thought people’s freedom was being restricted. This helped to protect people’s rights. Applications were made and advice taken to help safeguard people and respect their human rights. Staff had completed safeguarding training and showed they had a good knowledge on how to recognise and report concerns. Staff were able to describe the action they would take to protect people against harm and were confident any incidents or allegations would be fully investigated. People told us they felt safe.

People were supported to maintain a healthy, balanced diet. People told us they enjoyed their meals. We observed interactions during mealtimes. People were assisted at their own pace and not rushed.

People’s care records contained detailed information about how people wished to be supported. Records were regularly updated to reflect people’s changing needs. People’s communication methods and preferences were taken into account and respected by staff. People and their families were involved in the planning of their care.

People’s risks were well-managed and regularly reviewed to help keep people safe. Where possible, people had choice and control over their lives and were supported to engage in activities within the home and outside.

People and staff described the management as supportive, approachable and involved in people’s care. Staff talked positively about their jobs and took pride in their work. Visiting professionals and staff confirmed the management of the service were approachable and very good.

People’s opinions were sought. Audits were conducted to ensure the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and, where there were areas for improvement, these were shared for learning.

Inspection carried out on 16 June 2014

During a routine inspection

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

At the time of the inspection people told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Cedar Grange alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service.

Cedar Grange had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), and further staff training was planned. This helped to ensure that people�s needs were met.

Is the service effective?

At the time of the inspection we found the service to be effective. People, or their representatives, were usually involved in writing or reviewing their plans of care. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people�s needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw that there was good liaison and communication with other professionals and agencies to ensure people�s care needs were met.

Is the service caring?

We spoke with people being supported by the service. We asked them for their opinions about the staff that supported them. At the time of the inspection feedback from people was positive, for example, �I find the staff to be friendly, helpful and kind�.

Cedar Grange had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

At the time of the inspection we found the service to be responsive to changing care needs although staffing levels were an area of expressed concern for staff. Many people who lived at Cedar Grange had complex health needs and were either not able, or chose not to join in group activities. There was some, but inconsistent, evidence to show that people were routinely offered one-to-one time or group activities.

We found there was room for improvement with how the service sought people�s views about the care provided.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

At the time of the inspection we found the service to be well-led. Cedar Grange had a registered manager. A new senior nurse had been appointed and started on the day of the inspection.

We saw minutes of meetings held with the staff. This showed the management had consulted with staff to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

Inspection carried out on 18 May 2013

During a routine inspection

Although many people had limited verbal communication skills due to their physical and/ or mental health needs, we were able to speak with fifteen of the fifty two people resident, to seek their views of the service provided. We were also able to speak with some people�s relatives.

The majority of people were happy with the care and support they received. Comments included � I cannot find anything of fault,� the staff are �very good to me� and �I am very happy here�. Some people did say they thought there was at times not enough staff. The majority of people liked the food and said the staff were nice. We observed staff caring for people in a very professional manner. We had a meal with people who used the service and a choice was provided and the quality of the food was good.

Cedar Grange is a purpose built care home which has been open for approximately five years. Accommodation was designed, decorated, furnished and maintained to an excellent standard. When we inspected the home was clean and odour free.

A satisfactory system was in place regarding staff recruitment checks. There were some gaps regarding the provision of staff training. Quality assurance systems were generally satisfactory.

Inspection carried out on 6, 7 November 2012

During a routine inspection

Some of the people who used the service were not able to comment in detail about the service they receive due to their healthcare needs. We spoke to two visitors who told us that they were pleased their relative lived at Cedar Grange. We spoke to people and spent time observing people and staff over a meal period. We saw people�s privacy and dignity was respected and staff were helpful. We saw people chatted with each other and with staff.

During the observations we saw staff helping two people to mobilise. We also saw staff conversing with people when they were laying up tables for lunch. We saw staff assisting people to eat their lunch. We saw people talking to each other at lunch.

We witnessed staff interaction with people which was generally positive.

We heard care workers ask people what they would like to do and gave them ideas if they could not make a choice.

People experienced care, treatment and support that met their needs and protected their rights.

People we spoke with said that they enjoyed the food they received. We were told the food was of a good standard, and we saw the food provided at lunch was hot, well presented and in sufficient quantities. We saw people were offered choices at meals.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We found staff received appropriate professional development and supervision.

Inspection carried out on 20 February 2012

During an inspection in response to concerns

We spoke with people, who were able, about the care they received. They told us that they felt well cared for, one person told us that they 'had no complaints, that the food was nice and that staff come if you call them. I can remain independent'. Another said, 'they were quite happy with all aspects of their care, the staff are good, there are no specific problems'.

People said that the food was 'very good' and we saw that the lunch looked pleasant and

specialist diets were catered for. Staff were seen to be assisting people to eat as required.

People using the service did not comment on staffing levels.

Staff told us that they felt the levels of staffing each day was improving but they

would still like more staff. Management explained that a recruitment drive is ongoing as more nurses are still to be appointed. Staff also told us that communication was much improved.

Inspection carried out on 24 August 2011

During an inspection looking at part of the service

People who were able, told us that they felt cared for, one person told us that they �had a splendid bath � I will be wanting one everyday�.

People said that the food was �very good� and we saw that the lunch looked pleasant and specialist diets were catered for.

People using the service did not comment about if there was enough staff on duty. However, staff told us that they felt the levels of staffing each day was improving but they would still like more staff. Staff also told us that communication was seen to begin to improve.

Inspection carried out on 30 June 2011

During an inspection looking at part of the service

People using the service, who were able, told us that the home is very busy and that they sometimes have to wait for their care needs to be met. One person told us that �they are a bit short staffed here, if ring the bell for the toilet I have to wait 15 minutes for a helper�. They also said that �I couldn�t have a bath last week because they were short of staff�.

Another person told us, 'I used to have a bath every week, not now, maybe once a month now, i think this may be because they are short of staff'.

'Not enough staff, you have to wait a while, i don't want to be fussy but if they are busy, you have to wait longer'.

People were generally happy with the standard and choice of food. One person told us 'The meals and food are alright'. 'They will bring me a cup of tea and I am topped up with drinks'.

People told us that 'The majority of the staff are nice', another said, 'Its quite pleasant (here) really, most staff are lovely, they come and go'.

Inspection carried out on 24 January and 21 February 2011

During a routine inspection

We spoke with people using the service, who were able, and they told us that the staff were kind and caring. They told us that within the constraints of staff availability they could get up and return to bed when they wanted to. They told us that they had a choice in how they spent their day and that they could join in activities if they wanted to. People told us that sometimes there were not enough staff and that they had to wait to use the toilet. They said that some staff was more thorough than others. They told us that they felt staff turnover was high and this meant people using the service found it hard to get used to staff and then them leave.

Visitors also told us that staff turnover appeared to be high with new faces appearing regularly

Visitors told us that staff were always approachable and kind but felt that there was not always enough staff available in to ensure people had sufficient attention when they needed it. This was noted to be the case over the whole period of the day but most obviously in the later afternoon and evenings.

Staff told us that they liked working at the home but felt that they were sometimes placed at risk because staffing levels were not adequate to ensure that people�s needs were met in a timely way and that people�s safety was maintained

People told us that the standard and choice of food was very good, however, we were told that sometimes the meals were not hot enough.