Housing 21 - Cedar Court

Housing 21 – Cedar Court is specialist 'extra care' housing that can provide personal care for up to 40 people. At the time of the inspection 35 people aged 55 and over received care. People lived in self-contained flats across three floors of the service which is located in the London Borough of Lewisham.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

People told us they received good quality care and they had seen improvements in the support staff provided since the last inspection. The provider had processes in place to ensure suitable staff were employed to provide care and support. Staff were supported through ongoing supervision, appraisal and training.

Medicines were managed safely. The registered manager implemented the provider’s medicines policy to ensure staff administered medicines to people in a safe way. Staff were trained and assessed as competent to administer medicines. The quality of medicine administration records had improved since the last inspection and these were reviewed and checked for accuracy.

People had an assessment that considered their care and support needs. There were regular reviews of care records to ensure care was accurate and delivered in a safe way. Risk management plans were in place and these provided staff with detailed guidance on how to support people and to reduce and manage risks. Staff understood what abuse was and all staff had completed safeguarding training and they understood the importance of reporting any concerns in a timely way.

The provider had systems in place to monitor the service and the quality of care. The registered manager completed quality audits and reviewed the service to ensure care was of a good standard. Feedback was sought and people shared their comments about the service.

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.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update: The last rating for this service was requires improvement (published 3 June 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

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

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People's experience of using this service

People said the numbers of staff on duty did not always meet their needs.

People were at risk of deteriorating health because their medicines were not managed safely to keep them well to manage their medical health conditions.

There were some serious concerns raised about the openness and transparency of management of the service that had a potential impact on the care and support people received.

Staff had an induction, training, supervision and appraisal. However, we found some newly recruited staff had not completed the provider’s 12 week induction programme and had not completed essential training to support people.

People’s risk assessments were not always updated when their needs changed, increasing the risk of inappropriate care.

People had access to a complaints policy which they could use to make a complaint if they were unhappy with the care provided. However, some people told us they preferred to speak to care workers about any concerns they had.

The provider’s safeguarding processes was understood and followed by staff to ensure allegations of abuse were managed safely.

People and their relatives were involved in assessments and reviews of their care and support. People said staff were thoughtful, kind and provided care in a compassionate way.

People had meals that met their nutritional needs. Some chose to have their meals in their flats or in the day centre located on the ground floor of the service.

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.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 1 October 2018) and there were multiple breaches of regulations.

The service remains rated requires improvement. The provider had not completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had not been made and the provider was in continued breach of regulations related to safe care and treatment and staffing. We found new breaches of regulations in relation to person-centred care, good governance and fit and proper persons employed. We made four recommendations regarding the management of people's care records and exploring and celebrating diversity.

Why we inspected:

The inspection was prompted in part due to concerns received about medicines, staffing and management of the service. A decision was made for us to inspect and examine those risks.

Enforcement:

We have identified breaches in relation to medicines management, staffing levels, staff support, person centred care, management of the service and safe care and treatment.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Housing 21 – Cedar Court is specialist 'extra care' housing providing personal care to 40 people. At the time of the inspection 35 people aged 55 and over received care. People lived in self-contained flats across three floors of the service which is located in the London Borough of Lewisham.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

People gave mixed views about the quality of care they received. People and relatives were complementary about the care staff, but some felt their individual care needs were not always met by the service if this was not written in their daily care plan.

People did not always receive their medicines as required or as prescribed.

Staff were knowledgeable in the provider’s safeguarding procedures, understood abuse and how to report concerns about a person’s safety if they were at risk of harm and abuse.

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.

There were enough staff available during each shift to deliver care and support in line with people’s assessed care. The manager monitored the service and the of quality of care people received. 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 inspected but not rated (published on 21 November 2020).

Why we inspected

This was a planned inspection based on the previous rating. We had concerns about the management of the service because the management team had changed since the last 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.

This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed to requires improvement. This is based on the findings at this inspection.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to Safe care and treatment, Good governance and Person centred care. Please see the action we have told the provider to take at the end of this report.

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.

Housing 21 – Cedar Court is specialist 'extra care' housing providing personal care to 40 people. At the time of the inspection 35 people aged 55 and over received care. People live in flats across three floors of the service which is located in the London Borough of Lewisham.

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

People received their medicines as required. The provider had updated and reviewed their medicines audits, policy and processes. The current medicines management systems ensured people had sufficient stocks, accurate records and safe medicines administration to meet their individual needs.

There were new processes in place for staff handling people's money to reduce the risk of financial abuse. This helped to identify and mitigate any risks appropriately.

People and staff communicated well. People and their relatives told us care workers were helpful to them and provided care and support as they chose.

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 and staff were complimentary about the management of the service. Quality monitoring of staff practices and service records were completed to ensure these were of good standard.

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 (report published on 6 May 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met and to check on a specific concern we had about people being treated with dignity and compassion . The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

Housing 21 – Cedar Court provides care and support to adults living in specialist 'extra care' housing. At the time of the inspection, 38 people aged 55 and over were using these services. The service can support up to 40 people. People live in flats across three floors of the service that is located in the London Borough of Lewisham.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

People's experience of using this service

Medicines were not always managed safely. Records used by staff to confirm when people had their medicines were not completed accurately. Some medicine administration records contained unexplained gaps when people were scheduled to have their medicines administered. People were at risk of deteriorating health because their medicines were not managed safely to keep them well and manage pain. Medicine audits were completed by senior care staff, however, these checks did not find the errors we found.

Risks were not always safely assessed and mitigated appropriately. When staff handled people’s money the financial records were not always accurate, increasing the risk of financial abuse.

People told us that the care workers were not always kind, compassionate or cared for them in a dignified way.

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; the policies and systems in the service did not support this practice.

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 (report published on 21 January 2020) and there were multiple breaches of regulations. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulation 12 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. CQC are currently trialling targeted inspections, to measure their effectiveness in following up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

When we inspected people raised concerns that care workers were not always kind and caring, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe, caring and well-led. The overall rating for the service has not changed following this focused inspection and remains requires improvement.

Enforcement

We have identified breaches in relation to poor medicines management, how staff treated people when they were receiving care and support and the unsatisfactory management of people’s money. We also found the governance systems were not effective and staff had not always treated people with dignity and respect.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Housing 21 Cedar Court provides personal care and support for up to 40 people aged 55 and over. At the time of inspection, 37 people were using the service and one person was in hospital. This service provides care and support to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is rented, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care and support service.

Accommodation is located over three floors, which is wheelchair accessible with lift access to all floors. There are communal areas, solely for the use of people living at Cedar Court, including a living room and quiet room on the first floor. Care staff are available on-site 24-hours a day.

At this inspection, we found that people had not always received safe and appropriate care. Staffing levels were not sufficient to meet people’s needs. Risk assessments and management plans were in place. However, these were not always reviewed and updated in a timely manner to ensure staff provided care in a safe manner. Staff did not support a person to transfer safely from a chair to a wheelchair.

There was no registered manager. The previous manager left the service in May 2018. A manager had been appointed and would be applying for registration with the Care Quality Commission. 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 received the support they required to take their medicines. Medicine errors were identified and resolved.

Staff understood the safeguarding procedures to follow to identify and report abuse. Accidents and incidents were reported and action taken to minimise the risk of a recurrence. People received care from staff deemed suitable to provide support. Staff followed good infection control and prevention practices.

Staff morale and teamwork varied amongst team members. The provider had restructured the service and had put plans in place to support staff. Staff had started to see the benefits of the management’s intervention in building a cohesive staff team. However, it was too early to see how consistent and embedded the new culture will be. Some staff felt unable to approach the managers and highlighted some disharmony within the team. Some staff felt unsupported in their roles and were not confident their concerns were taken seriously. People using the service did not feel comfortable naming staff where there were concerns.

The provider worked with other agencies to deliver high standards of care. Audits were carried out on the quality of the service. Improvements were carried out although some shortfalls were not always identified and/or acted on.

We found two breaches of regulation relating to safe care and treatment and staffing. You can see what action we told the provider to take at the back of the full version of this report.

When we last visited the service on 23 May 2014, the service was meeting all the regulations we checked.

Housing and Care 21 – Cedar Court is extra care sheltered housing for older people. Personal care is provided to people who require it. At the time of the inspection 35 people were using the personal care service provided by Housing and Care 21 – Cedar Court.

The manager in post was new and had not yet registered with CQC as the 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.

Medicines were handled and administered safely. Staff understood the organisation’s medicines policy and followed it to ensure people received their medicines safely. Medicine administration records were completed accurately.

Risk assessments were in place and detailed actions to manage identified risks and to keep people safe. These covered risks associated with people's care, their environment and their health conditions.

Recruitment procedures were robust and safe. Only members who had successfully completed all checks including references and disclosure barring checks were allowed to work at the service. Staff understood how to recognise signs of abuse and how to protect people from the risk of abuse. Records showed that safeguarding concerns were taken seriously and investigated.

Staff understood their responsibilities within the Mental Capacity Act 2005. Staff were supported through effective induction, supervision, appraisal and training to provide an effective service to people. Staff were supported and supervised through one-to-one meetings, spot checks and observation. They told us it helped improved their performance.

The service worked with social care and health care professionals. People were supported to arrange appointments to ensure their health needs were met. Relevant professionals were involved to ensure people received appropriate support and care that met their needs. People were supported to eat and drink appropriately and to meet their dietary and nutritional requirements.

People told us staff treated them with kindness, compassion and respect. Staff provided support to people in the way they wanted to be cared for. People and their representatives were involved in their care planning and these were reviewed and updated regularly to reflect people’s changing needs.

People, their relatives and staff were encouraged to provide feedback and to raise concerns. The registered manager investigated and responded to complaints and concerns appropriately to improve the service. The service had various and effective systems to monitor the quality of service delivered. They worked in partnership with other agencies to deliver effective service to people.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and staff supporting them and from looking at records. We spoke to five people using the service out of 34, five relatives and five staff.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff were trained in their roles to support people safely. There was a safeguarding policy in place and staff understood the types of abuse and how to report it. Risks were assessed for people and actions were taken to address any risk promptly. Staffing levels were adequate and they were trained and competent in their roles. There was a plan for how to respond to unforeseeable emergencies. Medication was handled safely. The service was covered by care staff 24 hours a day and people told us they felt safe living at the service. Incidents and accidents were recorded and reviewed and lessons learned were discussed with staff. Equipment was assessed and provided for people who had mobility problems and staff had received training in using these.

Is the service effective?

People's care was planned and delivered in a person centred way. People were involved in their care planning. The provider involved other healthcare professionals in the planning and coordination of people's care and treatment. We saw evidence of the involvement of a speech and language therapist (SALT) in supporting one person with swallowing difficulties and recommendations were implemented by staff. Staff responded to alarm calls promptly and flexibly to meet the needs of people. People were supported to access activities taking place at the service.

Is the service caring?

Staff understood the needs of people they supported. People using the service told us that they were treated with dignity and respect. One person said, 'Staff are nice and they look after me well.' Another said 'The staff are good. They do a good job.' We observed staff interacted and responded to people in an open and positive manner. People's care plans detailed their likes and dislikes and care delivery centred on what people needed, and reflected their preferences, interests, and choices.

Is the service responsive?

People's choices and independence were promoted by staff in the way they were supported. One person told us 'I'm encouraged to do as much as I can for myself.' We saw staff attending to calls from people and responding to alarm bells. There were activities within the service which people participated in. The provider liaised effectively with other health and social care professionals to ensure the service responded to people's needs. Care plans were reviewed and updated to reflect changes in their needs and circumstances. Additional care support was implemented if required.

Is the service well-led?

The provider worked well with other agencies in meeting the needs of people using the service. There were quality assurance systems in place to identify, assess and monitor the quality of service provided. We saw records of complaints and actions taken to address them. People using the service and their relatives told us that management take complaints and comments seriously and sort things out quickly.

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The provider also had an effective system to assess and monitor the quality of service that people received. They regularly received feedback from staff and people using the service through the use of meetings and surveys.

There was some evidence that people were not being protected against the risks associated with the use of medicines. This was because records of the use and disposal of medicines were not kept accurately. This meant that there was some moderate risk to the people using the service because it was not possible to tell if people had taken the correct amount of medicine.

We also found that the provider was not able to respond to unexpected changes in the service, such as sickness cover or other staff absence. This had a moderate impact on the safety and welfare of the people using the service because their care needs were not always met in a timely manner.

At our visit on 5 February 2013, we saw that the provider had taken steps to ensure that there were effective systems in place to reduce the risk and spread of infection and that infection control training had been attended by most staff.

There were enough qualified, skilled and experienced staff to meet people's needs at all times, and staff were being supported, through training and supervision, to deliver care and treatment safely and to an appropriate standard.

People understood the care and treatment choices available to them. Copies of care and support plans were available in people's flats, and they told us that their keyworkers had discussed the plans with them and that their views were taken into account by their carers.

Staff at Cedar Court met peoples' individual health and care needs well. People we spoke with told us that they had rarely had to raise any issues, but that if they did, staff responded quickly and tried to find solutions to address the problem.

People felt that their privacy and dignity and independence were respected. One person told us 'I've got my own flat, I can come and go as I want but with back-up. I want my independence.'

However, there had been staff shortages and while these had not significantly impacted on the core tasks or care given to people, staff told us they were finding it difficult to cover all their required tasks. The provider had responded by recruiting a number of new staff, but they had not yet started working at Cedar Court.

Additionally, although communal areas and flats at Cedar Court were visually clean, we found that infection control training had not been made available for all staff and not all staff were following appropriate infection control practices.