Archived: Cedars Residential Care Home

At our inspection on 25 and 28 June 2015 we found that the service required improvement and was rated Inadequate with regard to its safety. At our last inspection on 6 and 28 July 2016 we found that the service had not made the required improvements and was in breach of eight regulations. We made requirement actions for these breaches, rated the service Inadequate and placed the service into Special Measures. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, are inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

At this inspection we found that, although some improvements were evident, the required improvements had not all been put into place and our concerns about the safety and effectiveness of the service remained. The overall rating for this service remains ‘Inadequate’ and the service therefore continues to be in special measures while we consider our regulatory response which, in line with our enforcement policy, may lead to taking action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

The service provides accommodation for up to 63 people, some of whom are living with dementia. At the time of our inspection 57 people were resident. The service is split into two buildings which operate quite separately.

A registered manager was 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.

Risks were assessed and documented in care plans but staff did not always manage risks effectively and people were not always safe. We continued to see practices which placed people at risk, including poor moving and handling techniques.

The provider did not have sufficient oversight of the safety of the service and risks were not effectively monitored. The service was not always proactive in managing the risks related to the prevention of pressure sores for people with limited or no mobility.

Infection control measures were in place and concerns highlighted by our previous inspection had been addressed.

There were not always enough skilled and experienced staff to meet people’s needs promptly. There was a lack of strategy in place regarding the deployment of staff. There was a recruitment procedure in place but the skills and experience of staff was not clearly established and verified before employing them. Staff received an induction and the training they needed to carry out their roles but staff practice did not always demonstrate that they put this learning into place.

Staff were trained in safeguarding people from abuse and the manager referred incidents appropriately to the local authority safeguarding team for investigation.

Medicines were managed safely and well. Staff were trained to administer medicines and their competence to do this was checked.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals and relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. The service did not always act accordance with the MCA and staff did not demonstrate a good understanding of DoLS.

People who used the service praised the food and people were referred to dieticians if they required this. Support at mealtimes for people who needed help or encouragement to eat and maintain their weight varied and in some cases was poor. Oversight of people’s nutritional needs and recording related to this was not always good, although some improvement was evident.

Some staff were very caring and treated people respectfully, ensuring their dignity was maintained. Others were less caring and did not consider people’s dignity and comfort.

People were involved in planning and reviewing their care but this was not always evident for those people with significant needs related to their advanced dementia.

People were not supported to follow a wide range of hobbies and interests. People living with dementia and those unable to go out independently lacked stimulation and most people were not meaningfully occupied. Staff understanding of the needs of people with dementia was poor.

A complaints procedure was in place but records did not always show how issues raised were followed up or actions taken.

Staff felt they were well supported by the management team and found them approachable.

Systems designed to assess and monitor the quality of the service were in place but were not always effective. The provider had oversight of issues affecting the service but did not have an effective management system in place to bring about the required improvements and motivate and manage the staff to deliver these.

We found several continued breaches of regulations during this inspection. We have also shared our concerns with the local authority contracts and quality and improvement teams.

At our previous inspection on 25 and 26 June 2015 we found that the service required improvement and was rated Inadequate with regard to its safety. An action plan was submitted to the commission which stated that measures would be put in place to improve the service and ensure that people who used the service received safe and effective care. At this inspection we found that the required improvements had not all been put into place and our concerns about the safety and effectiveness of the service remained.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special Measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

The service provides accommodation for up to 63 people, some of whom are living with dementia. At the time of our inspection 57 people were resident. The service is split into two buildings which operate quite separately.

A registered manager was 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.

Risks were assessed and documented in care plans but staff did not always manage risks effectively and people were not safe. The provider did not have oversight of the safety of the service and risks were not well monitored. We found that, in particular, risks related to scalding and infection control were not well managed. The service did not effectively manage risks related to the prevention of pressure sores for people with limited or no mobility.

Although people told us they felt there were sufficient staff on duty but we found there were not always enough staff to meet people’s needs promptly. There was a lack of strategy in place regarding the deployment of staff. Staff recruitment was not robust.

Staff were trained in safeguarding people from abuse. However we found that some staff were not skilled in managing people’s behaviour when they became distressed and this sometimes placed other service users at risk. The management of the service referred incidents appropriately to the local authority safeguarding team.

Medicines were managed safely. Staff were trained to administer medicines and their competence to do this was checked.

Established staff received the training they needed to carry out their roles but staff practice did not always demonstrate that they put this learning into place. New staff were not recruited robustly and did not always receive an effective induction which covered all the core skills they would need to carry out their role safely and effectively.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals and relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. The service did not always act accordance with the MCA and staff did not demonstrate an understanding of DoLS.

People who used the service praised the food and people were referred to dieticians if they required this. Support at mealtimes for people who needed help or encouragement to eat and maintain their weight was poor. Oversight of people’s nutrition was poor and kitchen staff did not assure us that they had a good understanding of the principles of good nutrition for people living with dementia or diabetes.

Some staff were very caring and treated people respectfully, ensuring their dignity was maintained. However some staff showed a lack of patience and understanding of people’s health conditions and did not respond appropriately or kindly to people’s distress and anxiety.

Although most people, and their relatives, were happy with the level of involvement in planning and reviewing their care, some people did not feel they had been sufficiently involved.

People were not supported to follow a wide range of hobbies and interests. People living with dementia, and those unable to go out independently, lacked stimulation. Activities were provided on each of our inspection days to a small minority of people.

Formal and informal complaints were managed well and to people’s satisfaction.

Staff understood their roles and felt they were well supported by the management team but showed a lack of accountability and responsibility in some cases.

Systems designed to assess and monitor the quality of the service were in place but were not always effective. The provider did not have a clear oversight of the issues affecting the service and did not demonstrate strong leadership. The health and safety of the service was not adequately monitored and poor practice found at the last inspection, and which had placed people at risk, was still of concern at this inspection. The service was not clean and there were no clear procedures and processes related to the regular cleaning and monitoring of the service. The provider had not been proactive in establishing a robust recruitment and induction procedure for new staff.

We found several breaches of regulations during this inspection. You can see what action we have told the provider to take at the back of this report. We have also shared our concerns with the local authority contracts, quality and improvement, and environmental health teams.

We spoke with five people using the service and they told us they were happy with the care and support they received. One person said, 'They are all kind here'. We observed staff during the lunchtime and found they were supportive and respectful. We found that staff were compassionate to older people's needs.

In addition we looked at matters raised in a whistle blowing from information received from a staff member. We found that these matters had generally been addressed and did not have concerns. We did however give feedback, noted in this report, about how the service could improve infection control practices but found that currently there had not been any detrimental impact upon people using the service.

We found that the service made sure that equipment was provided to meet people's needs and that it was regularly maintained and serviced.

We found that the correct checks were done before staff began working at the service. However we found that some staff had not been given the training they needed to carry out their roles safely and effectively.

We observed some poor practice with regard to involving people in their care and treating them with dignity. We were alerted to a possible safeguarding incident which we found the provider had not investigated. This lack of investigation could have put the people who use the service at risk.

This service was not responsive to feedback from staff or people who used the service and needed to develop better systems of listening and learning from incidences.

We found that suitable arrangements had been put in place for the management and prevention of pressure areas. This meant that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

The majority of care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Risk assessments and plans were in place for falls prevention, moving and handling and working with people who displayed behaviour that challenged. We have made a compliance action as not all practice in relation to pressure area care prevention protected people's safety and welfare.

We noted that the provider had suitable arrangements in place to ensure that people were protected against the risk of abuse and prevent abuse from happening. One person told us that they "Would have no hesitation in speaking to the manager should they have any concerns".

Appropriate arrangements were in place for the management of medication. There were effective recruitment and selection processes completed for each staff member before they started work with vulnerable people. Relatives and people we spoke with at the service felt that the staff were kind and looked after people well.