Archived: The Cedars

The Cedars provides personal care and accommodation, for up to 42 older people some of whom are living with dementia. The purpose-built building consisted of three floors. At the time of the inspection The Cedars was fully occupied.

Peoples experience of using the service:

People were cared for by staff in a way that kept them safe and protected them from avoidable harm. Enough staff were available to respond to people’s needs in a timely manner. People received their medicines when they needed them, and systems were in place to ensure that medicines were stored and administered safely and that adequate supplies were available. Accidents and Incidents were investigated, and measures were taken to prevent re-occurrences. The premises were clean, and staff knew and followed infection control principles.

People gave us positive feedback about the quality of care they received. The feedback on the leadership of the service and the registered manager from people and staff was positive. There were effective governance systems in place to monitor the quality of service and the health, safety of welfare of people. 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 (report published 19th February 2019). You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Cedars on our website at www.cqc.org.uk.

Why we inspected

We undertook this focussed inspection due to complaints we had received that The Cedars was not supporting people safely and that staff did not interact with people using the service in an appropriate manner. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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 remained the same.

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.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Cedars 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 reinspection programme. If we receive any concerning information we may inspect sooner.

At this inspection we found improvements had been made and the service was rated Good overall with Requires Improvement in Well-Led.

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

The Cedars accommodates up to 42 people in one adapted building. At the time of the inspection there were 41 people using the service.

There was a registered manager in post at the time of our inspection. 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.

The governance systems had not ensured staff consistently followed the procedures for safeguarding people. The system had not ensured risk assessments were not consistently updated following a change in people’s needs.

People’s medicines were administered as prescribed. Risks to people were assessed and planned for to keep them safe. Staff were safely recruited. People were protected from the risk of cross infection. The provider learned when things went wrong.

Staff were supported in their role and had access to training. People were supported to live in an environment which was suitable to meet their needs. People could choose their meals and were supported to eat and drink. People were supported to maintain their health and well-being.

People had choice and control of their lives and staff were aware of how to support them in the least restrictive way possible; the policies and systems in the service were supportive of this practice.

People had their privacy and dignity protected. People were supported to make choices and staff promoted people’s independence. People’s communication needs were assessed and planned for.

People’s preferences were understood by staff. People had access to a range of activities. People were clear about how to make a complaint and these were responded to. There was nobody receiving end of life care at the service so this was not considered during the inspection.

Notifications were submitted as required and the registered manager understood their responsibilities. People and their relatives were engaged in the service and felt able to approach the registered manager.

The Cedars are registered to provide accommodation with personal care for up to 42 people. People who use the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection the service supported 34 people.

There was a registered manager at the service. However, the registered manager was not available during the inspection and the service was being managed by a regional support manager and district 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. Our records showed another manager who was previously employed by the provider was still showing as a registered manager. The provider told us that they had requested that this manager deregister with us (CQC), but this had not been completed.

Risks to people’s health and wellbeing were not consistently managed or followed by staff to ensure people were supported safely.

We found that medicines were not always managed in a consistent and safe manner and they were not always administered as prescribed.

People were not consistently protected from the risks of abuse because staff had not always followed the provider’s policy for recognising and reporting possible abuse.

The provider did not have effective systems in place to consistently assess, monitor and improve the quality of care. This meant that poor care was not always identified and rectified by the registered manager and provider.

We received mixed experiences from people and their relatives about the availability of staff. However, during the inspection we saw that there were enough staff available to meet people’s needs in a timely way.

Staff told us they received training. However, we found that some of the training they had received was not effective and improvements were needed to ensure staff had sufficient knowledge to support people safely.

Some improvements were needed to ensure the provider had evidence that people were supported with decisions about their care and treatment by legally appointed representatives.

People did not always receive caring support because the provider had not ensured that they were protected from potential harm.

Improvements were needed to ensure people’s end of life wishes were taken into account to ensure they received care that met their wishes at this time of their lives.

People and their relatives knew how to complain. However, some relatives were unhappy with how complaints had been handled. The provider had recognised the shortfall in complaint handling and improvements were being made to ensure that complaints were handled in line with the provider’s policy.

Improvements were needed to ensure people felt involved in the planning and reviews of their care. Reviews of people’s care were not always effective in identifying a change in people’s needs.

Systems were in place to ensure that people received the least restrictive care and treatment to keep them safe and staff understood and followed the Mental Capacity Act 2005.

People were supported with their nutritional needs and action was taken to ensure people at high risk of malnutrition were supported effectively.

Advice was sought from health and social care professionals when people were unwell, which was followed by staff.

People’s choices were promoted and respected by staff. People were treated with dignity and respect and their right to privacy was upheld.

People were supported to access hobbies and interests that were important to them.

The provider had identified the shortfalls in the quality of care and had implemented an improvement plan. This showed that the provider was working towards improvements to the care people received.

People, relatives and staff felt able to approach the new management team and the provider had asked for feedback and been open about the improvements needed.

The inspection took place on 9 November 2016 and was unannounced. The Cedars is a residential home for up to 42 people who have a variety of support needs, such as older people and people with dementia. There were 36 people living at the service at the time of the inspection.

There was a Registered Manager in post at the time of our inspection. 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 identified a breach 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 the full version of the report.

Not all staff were caring and people were not always treated with dignity and respect. People’s choices were not always respected, their dignity was not always maintained and we observed a person who was not able to speak to their relatives at a time that suited them.

All safeguarding allegations should be reported to the local safeguarding authority however we found an instance of one allegation that had not been reported. Other safeguarding incidents had been correctly reported to the local safeguarding authority.

Although we saw examples of staff using correct moving and handling techniques we did observe one example of poor practice and also an example of a person being hoisted in an undignified manner. A visiting professional told us they had seen other instances of this whilst they had been visiting.

PRN protocols were not always in place for people that had medicine that was to be taken ‘when required’ and some people were not getting their medicine as prescribed. Medicines were stored in line with guidance.

There were sufficient numbers of staff to support people however a proportion of staff were not permanent and were supplied by an agency. These agency staff members did not always know people’s needs which could have put people at risk.

The principles of the Mental Capacity Act 2005 (MCA) had not always been followed. Assessments had not always been carried out to help determine if people the staff felt did not have capacity were still able to make decisions and what type of decisions. Evidence of Lasting Power of Attorney (LPOA) had not been consistently sought and those who did have an LPOA did not always have the correct one in place regarding health and welfare for people who lacked capacity.

We saw examples of poor moving and handling practice and poor practice in relation to supporting people with dementia such a things not being explained to people. This meant the training had not always been effective in helping staff support people.

Care plans were not always personalised and did not always contain full information about people and their preferences. Staff did not always know people well and did not know their individual needs, as many staff were from an agency and not permanent employees. This put some people at risk of not having their needs met or not having their preferences catered for.

Poor practice had not been identified in relation to dignity and respect, moving and handling and safeguarding. Audits were in place and had identified areas for improvement. Some improvements had been followed through however some still needed to be completed.

People were starting to access the community and partake in hobbies.

People had access to other health professionals in order to maintain their health and wellbeing.

People were supported to have food and drinks of their choice that were appropriate for their needs.

Staff felt supported and had supervisions and most felt they could approach the manager or the provider.

Safe recruitment practices were in place and staff had appropriate checks prior to starting work to ensure they were suitable to work with people who used the service.

Staff and relatives knew who the manager was and felt able to go to them with queries. The manager had also been submitting notifications about the service, which they are required to do.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

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

Is the service safe?

People who used the service and their relatives told us they felt safe. One relative told us: 'My Mum is safe, they contact me when necessary'.

We saw that the service was clean and had procedures in place to reduce the spread of infection.

People had their medication managed in a safe way.

Recruitment procedures were rigorous and thorough.

Is the service effective?

People all had an individual care plan which set out their care needs. Assessments identified needs for any equipment, mobility aids and specialist dietary requirements.

We saw that the service supported people to access a range of health care professionals. On the day of our inspection some people were able to consult a visiting optician.

A relative told us: 'When my mother went into hospital, a member of staff went with her'.

Is the service caring?

Staff were kind to people and treated them with dignity and respect.

A person who used the service told us: 'I love those girls, they are good to us'.

Is the service responsive?

Regular resident and relative meetings took place to involve people in the running of the service. A relative told us: 'If I needed to make a complaint, I am sure it would be listened to'.

People had access to meaningful activities throughout the day.

Short term care plans were implemented when a person's needs changed.

Is the service well led?

The service had a quality monitoring system in place to ensure the quality of the service provided was maintained and improved.

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

Staff were supported by the manager and had the appropriate training to fulfil their role effectively.

During our inspection we spoke with six people who used the service, six members of staff and the registered manager. We also spoke with five people who visited the service. The majority of people and their relatives told us they were happy with the care. One person told us, 'I'm very happy here, the staff are good and caring'. A relative told us, 'I think it's marvellous. The carers are so pleasant'. Another relative told us they didn't feel confident that their relative was safe. They said, "I can't go home and relax and think that everything is all ok".

We found that people had support plans which described the care and support they required to keep them safe. However, we saw that these plans were not always followed.

There were systems in place to ensure that the premises and equipment were suitable and in good condition. The design of the home was suited to people with a diagnosis of dementia.

Staff told us they had completed training in dementia, but we saw that staff had not been trained to support people to engage in meaningful activities.

There was an effective complaints system in place and we saw that the registered manager was responsive to people's complaints.

All of the people who used the service had dementia and were not able to always communicate effectively with us. To ensure they were receiving the support they needed we observed how staff interacted with them and the care practice in the home. People we spoke with commented as follows, "I'm alright, the foods good and I like it".

We saw that care records included information about how people needed to be supported and how risks had been assessed. People received the health care and treatment they needed.

Staffing levels were usually sufficient to meet people's needs and staff received the training they needed to support people.

People's personal records were maintained, regularly reviewed and stored securely which ensured confidentiality and data protection.