The Cedars Nursing Home

On the first day of the inspection the provider’s visiting policy was not in line with current Government guidance. This was preventing one person’s family members visiting them inside the building. Following our visit, we had further contact with the manager regarding visiting arrangements. The manager informed us the provider was making changes to their visiting policy, which would mean the person’s family members would be able to visit them inside the building, in line with current Government guidance.

We found the following examples of good practice.

The service had introduced measures to prevent visitors from catching and spreading infections. Visitors were screened for symptoms of COVID-19 and were provided with personal protective equipment (PPE).

Staff had received training on infection prevention and control measures and how to use PPE safely. PPE was available to staff throughout the service and staff were seen using it effectively.

Additional cleaning measures had been introduced in the home. All areas of the home were clean, and records demonstrated the additional cleaning had been completed.

COVID-19 testing was being carried out for people using the service and staff in line with the latest guidance.

The provider had effective systems in place to check staff and professional visitors were vaccinated against COVID-19.

The provider had updated their infection prevention and control policy to reflect the COVID-19 pandemic and additional measures that had been introduced.

The Cedars Nursing Home is a care home providing personal and nursing care to 39 people aged 65 and over at the time of the inspection. The service can support up to 59 people.

People live in two areas of the building, one of which specialises in providing care to people living with dementia. Part of the care home is undergoing refurbishment which is sectioned off from the main part of the building.

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

This was a targeted inspection in response to information received about low staffing levels at night impacting people’s care, that people were being woken up early and monitoring documentation had not been completed.

During our inspection we found no concerns in relation to these areas. We visited the service in the early hours to corroborate the information of concern.

Staffing levels were appropriate and in line with the services assessment of people’s support needs. The atmosphere was calm with two people awake which was their choice. Risks to people were monitored and documentation completed. Staff had a good knowledge of people they supported and respected their privacy.

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 2021). As this inspection only considered the key question of 'Safe' we have not made any changes to this rating.

Why we inspected

We undertook this targeted inspection to check on concerns that were raised with us about specific practices at the home. The overall rating for the service has not changed following this targeted inspection and remains good.

CQC have introduced targeted inspections 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 reinspection programme. If we receive any concerning information we may inspect sooner.

The Cedars Nursing Home is a care home providing personal and nursing care to 39 people aged 65 and over at the time of the inspection. The service can support up to 62 people.

People live in three areas of the building, one of which specialises in providing care to people living with dementia.

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

People were safeguarded from the risk of abuse and received safe care and treatment. There were enough staff to meet people’s needs. Risk assessments and care plans were thorough and up to date and provided staff with enough detail to support people safely.

Medicines were managed safely and staff worked with health and social care professionals to help people maintain their health and well-being. The environment was clean and good infection control procedures were followed.

There were systems in place for communicating with people, their relatives and staff to ensure they were fully involved. This included one to one meetings, handovers and team meetings.

All essential visitors had to wear appropriate personal protective equipment (PPE). Additional cleaning of all areas and frequent touch surfaces was in place and being carried out and recorded regularly by staff.

Quality assurance processes were in place to monitor the service. Staff and relatives told us that the registered manager was approachable, and staff were confident that action would be taken if they raised concerns.

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 6 April 2020).

Why we inspected

We received concerns in relation to staffing levels and the management of pressure sores. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well-led sections of this full report.

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.

The overall rating for the service hasn’t changed from good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Cedars Nursing Home on our website at www.cqc.org.uk.

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 providing nursing and personal care to 41 people aged 65 and over at the time of the inspection. The service can support up to 62 people.

People live in three areas of the building, one of which specialises in providing care to people living with dementia.

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

Improvements had been made to the service since the last inspection. People felt the management team had a good understanding of any issues in the home. The quality of the service was regularly assessed, and action taken to make improvements where needed. However, the service did not have a registered manager and notifications were not always made to us when necessary. We have made a recommendation about ensuring management staff are clear about the responsibility to inform us of certain events in the home.

People said they felt safe living in the home and staff supported people to manage the risks they faced. People received support to take the medicines they had been prescribed. There were enough staff to provide the care that people needed.

People were supported to have maximum choice and control of their lives and staff supported support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People liked the food provided by the home and staff helped people to eat and drink where required. People were able to access the health services they needed. Staff received suitable training to give them the skills to meet people’s needs.

People received caring and compassionate support from kind and committed staff. Staff respected people’s privacy and dignity. People and their relatives were positive about the care they received and about the quality of staff.

People were supported to take part in activities they enjoyed. People were involved in planning the activities schedule. Opportunities had been developed for people who were unable to participate in group activities to help ensure people did not become socially isolated. People had been supported to develop care plans that were specific to them. These plans were regularly reviewed with people to keep them up to date.

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 8 March 2019) and there were breaches of regulations. 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 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.

This inspection took place on 20 September 2018 and was unannounced. We returned on 21 September 2018 to complete the inspection.

The service did not have 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 and associated Regulations about how the service is run. A manager was in post and they had submitted an application to be registered with us.

The home did not have effective systems to safely manage people’s medicines. People did not always receive the medicine they had been prescribed and staff did not keep accurate records of the medicines they had administered.

Risks people faced were not always effectively managed. Information in risk assessments was not always up to date and plans were not always amended following changes to the risks people faced. This increased the risk that staff would not have the information and guidance they needed to follow safe practice.

The registered person had not ensured everyone using the service had an accurate, up to date care plan, which set out how their care and treatment needs should be met. Care plans did not always contain detailed information about how to meet people’s needs in the way that they wanted.

The provider had failed to ensure the home has been well-led since 2014. We have completed four comprehensive inspections since July 2014. At each of these inspections we have assessed the service to either be in breach of regulations or require improvement to ensure people received a good service. Action has been taken to address specific issues we have identified, but subsequent inspections have identified further areas of concern.

Systems to track incidents and accidents and plan actions to minimise the risk of them happening again were in place, but had not been used effectively by the management team. Quality assurance systems had identified shortfalls in the service, but the service did not have effective systems to plan and achieve the improvements that were necessary.

People who used the service were generally positive about the care they received and praised the quality of the staff and management. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy and responded to requests for assistance.

People told us they felt safe when receiving care. Systems were in place to protect people from abuse and harm and staff knew how to use them.

Sufficient staff were deployed to meet people’s needs safely. People’s needs were kept under review and staffing levels had been changed where necessary.

People had regular meetings to provide feedback about their care and there was an effective complaints procedure. People were supported to take part in social activities that were suitable to their specific needs and wishes.

Staff demonstrated a good understanding of their role and responsibilities.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

This inspection took place on 24 May 2017 and was unannounced. We returned on 25 May 2017 to complete the inspection.

At the last comprehensive inspection in January 2016 we identified that the service had taken action to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, further work was required to ensure these improvements were embedded in practice and sustained. During this inspection we found that the provider had made further improvements in most aspects of the service provided to people. However, staff did not always communicate in ways that demonstrated respect to people and the service did not have a registered manager in post.

Staff did not always work in ways that were person centred or treated people with dignity and respect. During the inspection we observed staff talking over people who use the service, staff providing support to people without speaking to them or explaining what they were doing and staff using language that did not demonstrate respect for people.

Feedback from people who use the service about the approach of staff was mixed. One person said that they were “Very happy” living at The Cedars and added “The staff are lovely.” However another said “Some (staff) stand around talking to each other over me.” One person’s relative felt that there was a lack of social interaction and support between staff and their relative, particularly at meal times. “They come in, just push the plate at her and then their off. No offer of help.”

We also saw some good interactions from staff, where they worked in ways that were respectful of people and explained what was happening.

The service did not have a registered manager in post. Following the last inspection in January 2016, the provider recruited a new registered manager, but they left their post at the service in April 2017. The regional manager informed us a new manager had been recruited, but they left the service after a few weeks in post. The provider had a condition of registration that a registered manager must be in post at The Cedars and was therefore in breach of their conditions of registration at the time of the inspection. The regional support manager told us she intended to submit an application to register as the manager of the service until a new manager was recruited and registered. We will monitor this and will consider further enforcement action if the service continues to operate without a registered manager.

People said they felt safe living at The Cedars Nursing Home. Comments included, “Oh yes very safe. I have a laugh with the carers; they are very nice”, “Yes it’s alright. I think I have fallen on my feet here. The best thing is that I feel secure” and “It’s ok, I’m happy here; they are nice people. I feel safe here”. Systems were in place to protect people from abuse and harm and staff knew their responsibilities to protect people and keep them safe from harm.

Staff understood the needs of the people they were providing care for. Staff received a thorough induction when they started working at the home. They demonstrated a good understanding of their role and responsibilities. Staff had completed training to ensure the care and support provided to people was safe and effective to meet their needs.

The provider regularly assessed and monitored the quality of care provided at The Cedars Nursing Home. The information from these assessments was used to plan improvements to the service provided.

This inspection took place on 12 January 2016 and was unannounced. We returned on 13 January 2016 to complete the inspection.

At the last comprehensive inspection in June 2015 we identified the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were not enough staff to meet people’s needs, medicines were not always managed safely, the infection control procedures were not always followed and the service was not well managed. We served warning notices to the provider as a result of the concerns we identified. We completed a focussed inspection in August 2015 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found the provider had sustained these immediate improvements, but further work was needed for people to receive a consistently good service.

Staffing levels were safe, but some people felt additional staff would help them receive a more personalised service. Staff were available to provide support to people when needed, including support for people to eat, drink and move around the home safely. Call bells were answered promptly and staff responded to verbal requests for assistance from people.

Most people told us they thought there were sufficient staff available. Comments included, “They come quickly when I ring”, “There are no long waits” and “Yes, I think there are enough staff”. Two people expressed concern about staffing levels, citing the time it took to answer call bells and the time they were supported to get into bed in the evening.

Relatives told us they felt the staffing levels were usually suitable to meet people’s needs. Comments included, “Having less people in the home means staff have more time to sit and talk to people” and “There are generally enough staff to meet (my relative’s) needs, but maybe having one more (on the wing for people with dementia) would be better”.

During this inspection we found the improvements to risk management systems had been maintained, although some further work was needed to ensure staff were recording and analysing incidents more effectively.

Medicines were being managed safely and infection control procedures were being followed, which helped to minimise the risk of cross infection.

Staff understood their responsibilities under the Mental Capacity Act 2005 and the action they needed to take if people did not have capacity to consent to their care.

People’s opinion of the effectiveness of the care and support they received varied. When asked whether staff supported them well one person replied, “They try to”. Another person said, “Some are good and some are just OK”. A third person said, “It’s very hit and miss. All very well meant. They have good intentions but not always the ability. Most of the nurses are very good”.

Although most staff had completed training in person centred care and care of people who have dementia, we observed some interactions in which this was not put into practice. This included completing tasks without interaction with the person and not listening to people's responses to questions. Other staff demonstrated they had understood the training they had completed. We observed staff interacting with people in a way that demonstrated a good understanding of their needs and a warmth towards them. The regional manager acknowledged that more work was required to embed the training into day to day practice for some staff.

At this inspection we found there had been an improvement in the information set out in people’s care plans. People’s records contained care plans relating to their specific needs and there was evidence the plans were updated when people’s needs changed. Some people told us they were involved in developing and reviewing their plans. Where people were not able to tell staff what care they needed, there was a record of who had been involved in making decisions.

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found -

Is the service safe?

People were treated with respect and dignity by staff. People told us that staff treated them well. People were cared for by staff who were aware of the risks to their safety and health and staff knew how to support them in a safe way. A comment from a relative told us “I come in everyday and have watched everything and have found nothing untoward.”

Staff we spoke with told us that they had attended safeguarding training and knew how to recognise and report abuse. They demonstrated their understanding of safeguarding issues and their responsibilities in reporting concerns.

Systems were in place to make sure that the manager and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The registered manager had submitted a recent application and had been trained to understand when an application should be made. This meant that people were kept safe from harm. There were effective systems in place where people did not have capacity and best interest decisions were made through a multi-agency approach.

There were arrangements in place to deal with foreseeable emergencies. We observed that the home had clear protocols to follow in case of emergencies, such as an outbreak of fire, or when a person went missing.

Is the service effective?

People we spoke with told us that they were generally happy with the care they received and their care needs were met. It was clear from observations and from speaking with staff that they had a good understanding of people's care and treatment.

We found staffing levels had not always been maintained and additional cover organised when required. This meant that people's needs were not always met. Some of the comments we received from people were “all carers are lovely people and they talk to you and are respectful” and “this is a lovely home”. We received several comments about shortages of staff including “most of the staff try really hard but they are run ragged” and “the care is very good here but they are so busy. I don’t think there are enough staff”. People we spoke with also told us “the staff do try to come straight away but quite often I have to wait because I need to be moved by two people” and “the staff are very kind but so, so busy. They don’t have time to stop and chat”.

Comments from visitors spoken with were variable. We received positive comments when we were told “very happy with care, everything works so well”. Some other relatives told us they had raised concerns in the past about some of the care provided but that improvements were being made; while others had concerns about the staffing levels over weekends. We were told “there just aren’t enough staff here. It’s obvious”.

The records of care that staff provided to people were not always accurate. There were gaps in records relating to people’s nutrition and the support they received to reposition to prevent pressure damage. This increased the risk that people would receive inappropriate or unsafe care and treatment.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. They demonstrated their knowledge about the people they cared for and understood their preferences in consenting to how they liked things to be done.

We observed excellent interaction between people and staff who consistently took care to ask permission before intervening or assisting. There was a high level of engagement between people and staff. Consequently people, where possible, felt empowered to express their needs and receive appropriate care.

We saw people were receiving care in a sensitive way. We observed people being supported in making choices about their daily routines and the activities they would like to do.

Is the service responsive?

The service responded to people's changing needs through regular review of the care they received. People had been involved in the care they received. Their needs, preferences and interests had been documented to help plan an individual service. Staff spoken with told us they had enough information about people's needs and demonstrated their knowledge about individual needs and preferences.

There was evidence of good communication in the management of people's care between the provider and external professionals such as GP, speech and language therapists and hospital consultants.

People had access to activities that were meaningful and were supported to maintain relationships with their families.

Is the service well-led?

Quality assurance processes helped to make improvements to the quality of the service where they were needed. Actions were recorded and followed up at regular intervals. The processes in place to monitor and audit were being reviewed and improved to provide a person centred approach.

Staff had a good understanding about their roles and responsibilities. Although staff had been supervised through observation of their work practice, there were no formal supervision arrangements in place.

We saw staff looked after people who had dementia in an appropriate way. People we met with on the dementia and other units were calm and staff treated them with respect.

Frail people who needed support from staff were given the care they needed. This included reducing risks to them from pressure ulceration and dehydration. Records, including care plans, were clear and reflected people's needs.

Medicines were administered to people in a caring and sensitive manner. Full records of medications were maintained. Medications were stored in a safe way.

A range of equipment was provided to meet people's nursing and care needs. A member of staff told us 'we've all the equipment we need.' There were systems to report faulty equipment and ensure it was taken out of use until it was safe.

The provider told us they were ensuring registered nurses understood the importance of good quality, accurate records. We spoke with three registered nurses, who confirmed they had received appropriate supervisory guidance.

The provider told us they were introducing a regular audit of care plans. We saw evidence of these, although it was early to assess their effectiveness. There had been a change of temporary manager of the home. We were told this had impacted on the introduction of the audits. A permanent manager was due to join the home in October 2012.

We spoke with three care assistants. They told us care plans were accessible and helpful. What staff told us, and what we observed of people's needs, matched with what the care plans told us. A visiting GP told us the registered nurses found information from the home's records quickly when necessary, and the quality of information was good.