Archived: Cedars (The)

People’s experience of using this service: The provider and senior staff had completed audits on the home to support quality checks. However, these checks had not prevented repeated and new shortfalls in the quality of service provision. The provider had failed to notify the appropriate authorities of safeguarding events and the commission of statutorily notifiable events.

There were enough staff to meet peoples' basic needs. Staff training was provided but did not always ensure people’s specific needs were covered. Staff recruitment procedures were not followed appropriately. Staff had not received regular supervision.

Care plans were not consistently person centred and there was a lack of detailed guidance within peoples' risk assessments for staff to follow.

Medicines were stored safely. Some improvements are required in relation to medicine administration and documentation. People had not received access to regular oral health and other appointments.

The service did not provide people with regular access to the local community and activities were lacking for people that did not partake in group activities.

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. However, the service had not followed guidance fully when making best interest decisions. We have made a recommendation about this.

People were supported for by a staff team who were kind and caring. Staff had good relationships with people and knew them well.

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 31 January October 2019). The service remains rated Requires Improvement. This service has been rated Requires Improvement since 2016 for over four consecutive comprehensive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected: This inspection was scheduled based on the previous rating.

Enforcement: We have identified eight breaches in relation to governance, risk assessments, medicine management, recruitment, staffing, the environment, and statutory notifications at this inspection. We placed additional conditions on the provider's registration to enable them to focus on making improvements.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We undertook this responsive inspection due to concerns that had been raised relating to the environment being unclean and presenting infection control risks. We found at this inspection the service was clean and infection control risks minimised although the records relating to medicines management and audits were poor and required improvements.

At the last inspection we found Safe and Well-led required improvement. At this inspection the rating for these key questions were still requires improvement. 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”

The service registered to provide a regulated activity with the Care Quality Commission in October 2010. The Cedars is a 'care home'. People in care homes receive accommodation and nursing or personal care as a 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 accommodates 28 people in one adapted building providing personal care for older people some of whom are living with dementia. At the time of our inspection 26 people were accommodated at the service.

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.

We found records relating to the management of creams required improvement along with counter signing medicines.

People were at times being supported by staff who had not received satisfactory checks to ensure their suitability to work with vulnerable people.

Records were not always available at the time of the inspection. This included audits, supervision records for one member of staff along with a risk assessment for a pet. The registered manager and provider sent us these following the inspection.

People had personal evacuation plans in place and checks were undertaken on equipment within the service.

Staff said improvements could be made to the staffing levels as their additional responsibilities of helping in the kitchen, cleaning and laundry meant that at times people’s care was later than planned.

The provider acknowledged staff support with rewarding staff and records confirmed conversations and support provided to the registered manager.

People, relatives, staff and professional’s views were sought so that improvements could be made.

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

The service registered to provide a regulated activity with the Care Quality Commission in October 2010.

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

The care home accommodates 28 people in one adapted building providing personal care for older people some of whom are living with dementia. At the time of our inspection 27 people were accommodated in the home.

At the last inspection the service was rated as Requires Improvement. We found at our last inspection a breach of Regulation 17 Good Governance. The provider sent us their action plan confirming how they were going to address the shortfall. At this inspection we found the quality of the audits had improved although some shortfalls were identified during the inspection. At this inspection we found the service remained Requires Improvement overall. However, the rating had improved from Requires Improvement in the Caring and Responsive domain to Good.

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 were at risk of infection due to poor storage of laundry and dirty equipment being stored in the laundry room.

People were supported by staff who washed their hands regularly. People had individual risk assessments in place however environmental risk assessments from pets living and visiting the service had not been undertaken at the time of the inspection.

Medicines administration charts (MARs) for topical creams did not always record the person had received their cream as prescribed MARs records did not always confirm how often creams should be applied. Medicines were stored safely within the home.

People were supported by staff who had received checks to ensure they were suitable to work with vulnerable adults.

People had mixed views on the amount of staff available to support them. At times, due to staff sickness and leave, the rota was under the planned staffing capacity for the day.

The registered manager undertook additional duties above their role such as answering the phones and the front door which could take them away from their management role.

People felt safe, although some staff required an improvement to their knowledge of recognising the different types of abuse and who to report it to.

People were supported by staff who received training and supervisions. However, staff were yet to receive an annual appraisal.

People had choice in the meals and had access to drinks throughout the day. Medical appointments were arranged when required.

People were supported by staff who were kind and caring and who provided them with dignity and respect.

People had personalised care plans that contained important information relating to their individual needs these were evaluated monthly and reviewed yearly.

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

The care home accommodates 28 people in one adapted building providing personal care for older people some of whom are living with dementia. At the time of our inspection 27 people were accommodated in the home.

At the last inspection the service was rated as Requires Improvement. At this inspection we found the service remained Requires Improvement.

Two breaches of legal requirements were found following the last comprehensive inspection. This was due to the provider failing to ensure the principles of the Mental Capacity Act 2005 (MCA) were being followed and people were receiving safe care and treatment in relation to their medicines and individual care needs. The provider sent us an action plan confirming how they were going to address these shortfalls.

A manager was in post at the time of our inspection. They were undertaking the registration process to be the registered manager of the home. 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.

At this inspection we found some improvements had been made to how the principles of the MCA were being followed. Although the home had no process for people who required as required medicines and people could be at risk of cross infection due to poor hand washing facilities. Audits were not always being undertaken regularly and robustly so that effective monitoring of the home was in place so shortfalls were identified and actioned. We found some shortfalls during the inspection relating to inadequate hand washing facilities and records where people’s care plans had no details of pressure relieving mattresses and there being no process for people who might require as and when medicines.

People could be at risk due to poor hand washing facilities within people’s rooms. There was no guidance or policy that supported people who might require medicines as and when.

People’s care plans contained guidelines for staff to following relating to moving and handling but not relating to pressure relieving mattresses. People were support by staff who had suitable checks prior to working with vulnerable people.

People felt safe and were supported by staff who were able to identify abuse and knew who to go to should they have concerns. Although some health care professionals felt people might not be safe.

People and staff felt improvements could be made to the recruitment of more staff.

People were not always being supported by staff who had received an annual appraisal. The manager was in the process of undertaking regular supervisions with staff to ensure their training was current and up to date. Additional training was provided and planned when required.

People felt supported by staff who were nice and kind. Staff demonstrated a good understanding of equality and diversity and how to promote people’s independence and respect their privacy.

People felt able to complain and care plan’s had important information relating to people’s likes and dislikes, hobbies and interests and any end of life wishes.

People and staff felt the management were supportive and accessible and felt able to raise concerns with them.

We recommended that guidance is sought relating to infection control guidelines.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The inspection took place on 17 August 2017 and was unannounced. This was a focussed inspection to look at issues arising from information of concern received by CQC.

The last comprehensive inspection of the service took place in October 2016. At that inspection we rated the service overall as ‘Requires Improvement’. As a result of this focussed inspection we have not altered the overall rating.

This inspection was focussed on the question; Is the service safe? We looked at; People's experiences and how safe they felt, recruitment, staff knowledge of safeguarding and whistleblowing, incident and accident reporting and, specific issues relating to medicine administration.

The manager registered with CQC was no longer working at the home at the time of our inspection. A new manager was in post and intended to start the registration process with us as soon as possible. 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 reported feeling safe and that staff were kind to them, providing support when they required it. Staff were knowledgeable and confident about reporting any issues of concern. Staff completed incident and accident forms when necessary.

People had no concerns about how their medicines were administered.

We found that overall systems for recruitment were mostly robust. Suitable checks were undertaken to help the manager make safe recruitment decisions. However, applicants full employment history had not always been assessed.

The Cedars provides accommodation and personal care for up to 28 older people including those with dementia. Some people at the home needed support to communicate verbally. During the inspection there were 25 people living at the home. The accommodation is arranged over two floors with bedrooms on both floors.. On the ground floor there are a number of communal spaces including a lounge, conservatory and dining room.

The registered manager had been registered for five months. A registered manager is a person who has been registered with the Care Quality Commission to manage the service. They are a ‘registered person’. 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. The registered manager was supported by a deputy manager and two seniors.

People told us they felt safe and we saw evidence. Some improvements were required with the way medicines were managed and equipment was checked. Medicines taken ‘as required’ rather than regularly did not have written protocols for staff to follow and the provider’s procedures for crushed medicines had not been followed.

When people lacked capacity to make their own decisions the principals of the Mental Capacity Act 2005 were not always followed. This meant some people were at risk of having their human rights breached.

The registered manager was developing quality assurance systems to help ensure people received good and safe care. Some concerns identified on the inspection had not been identified by the provider or registered manager.

There were enough staff to support people. There was a recruitment process in place but members of staff sometimes forgot to document all the checks completed. Staff told us they had an induction and had received a lot of training. The support staff received was through an informal process. People received care and support from staff who knew how to meet their needs.

Staff knew how to protect people from avoidable harm or abuse and had received training in safeguarding. They told us they would be confident reporting any concerns to the management and staff knew who to contact externally. The provider understood when they were responsible for informing the local authority and CQC about safeguarding.

People who required Deprivation of Liberty Safeguards to protect their human rights were in place and staff knew what process to follow.

People were able to see a wide range of health and social care professionals to meet their health and care needs. People’s choices were respected by staff. People with different religious beliefs and cultural backgrounds had these respected by staff because they attended services or spoke in their first language.

People enjoyed eating food they were given and told us they had a choice of meals, snacks and drinks. When people expressed they wanted something different it was provided.

People and their relatives thought staff were kind and caring and we observed positive interactions. The privacy and dignity of people was respected and people were encouraged to make choices throughout their day.

There were care plans for all individuals which included their likes and dislikes. These plans made people central to their care and any decisions made. The needs of people were reflected within their plans. Staff had excellent knowledge about people’s care needs.

People and relatives knew how to complain or had the information available if required. There had been formal complaints since the last inspection which had been managed in a timely manner.

The registered manager had a clear vision for the home and had systems in place to communicate this. People and staff were aware of these visions.

We have made a recommendation about staff supervision.

We have made a recommendation about quality assurance systems.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our inspection on 15 July 2014 found that people were not always protected from the risks associated with medicines. The storage temperature of medicines was not monitored and the records for liquid medicines and variable dosage pain relief medicines were not accurate. The provider wrote to us on 20 August 2014 and told us how they would achieve compliance with the standard.

During this inspection, we found that improvements had been made. The provider had ensured that medicines were stored at the appropriate temperature and the staff had ensured records that showed people's medicine administration were correct.

People who lived at The Cedars spoke positively about their experiences in the home. They told us the staff treated them kindly and with dignity and respect. People made positive comments about the standard of the care they received and the staff.

Where people had identified risks, for example with mobility, falls or diabetes, we saw that an appropriate assessment had been completed and a support plan to guide staff on how to support the person safely was in place. Where required, information from healthcare professionals was recorded to ensure staff supported people safely.

People were not always protected from the risks associated with medicines. Storage temperatures of medicines were not monitored and recording errors for liquid medicines and variable dosage pain relief medicines were identified.

Is the service effective?

People told us they were involved in care planning and decisions about their daily living. The care people received reflected the needs of each individual. The provider had systems to ensure person centered information was recorded. We saw the home had a system to review people's care needs on a monthly basis to ensure changes in people's needs were identified.

People told us they were happy with the care provided at The Cedars. One person told us, 'The staff are wonderful, I enjoy living here.' Another person said, 'They (the staff) are very, very nice here. They are all kind and very helpful.' People's relatives spoke positively about the staff at the home. One person's relative said, 'The care seems good here and the staff seem good here.'

Staff said that information was shared with healthcare professionals about people to ensure any changes in a person's care needs were highlighted. We also saw that people's needs were discussed a staff meetings. The home had an active communication book to ensure important information was shared between staff during shift changes.

Is the service caring?

People gave positive feedback about the staff at the home and the level of care they received. We spoke with people who had lived at the home for a long period of time and others that had recently moved into the home. A person who had recently moved into the home said the staff had been kind and caring whilst helping them adapt to their new environment.

We made observations where people received the support they needed and people told us their needs were met by staff. For example, where people needed pressure relieving equipment to reduce the risk of skin damage, the correct equipment was in use. People at the home told us that the staff were competent in their roles and they felt safe within the home.

Is the service responsive?

We saw that the service involved other healthcare professionals as required. For example, district nurses were involved when people used a catheter. We saw from people's care records that appropriate referrals had been made following a decline in a person's health.

The home had ensured that where a risk had been identified, for example a person's risk of falls had increased, that they had responded to their needs. For example, people were referred to a falls specialist or occupational therapist, and additional equipment such as a pressure mat had been considered.

Is the service well led?

Some aspects of the service were not well led as shortfalls had not been identified with the risks associated with medicines procedures.

We saw that there were systems in place to monitor the quality and safety of the service provided. This included surveys to gather the views of the people who lived at the home and their relatives.

We saw that there were systems in place to monitor the feedback from staff about how well the home was run. This included surveys and periodic meetings.

Any accidents and incidents that occurred in the home were recorded and analysed to establish any trends. We saw actions that reduced the risk of further falls to people was taken following this analysis.

Each person received good quality of support and were encouraged to express their views. People spoke positively about the service. People we spoke with told us they were "happy living in this home'.

People told us they felt involved in their care plans. Other people told us their families were involved instead of them. One person told us they 'love it here, because we're all just like one big family'.

We saw that staff were knowledgeable about people's support needs. We saw staff treated people respectfully and were courteous. For example, knocking on doors before entering people's rooms. We saw that staff spent time to reassure people when necessary.

The service had a quality assurance system in place that addressed complaints. We saw that concerns were acted upon within the timescales of the policy. People told us that they felt safe and were able to talk to staff if they had any concerns.

We saw that all care records clearly described each person's needs. One person told us "the staff know what to do", and 'they're all good at giving me what I want'.