This unannounced inspection was conducted on 16 and 17 January 2017.

Cedar Grange is a residential care home that provides accommodation and personal care to a maximum of 26 people living with dementia. The home is situated in Southport near to the town centre. The facilities are provided over two floors with a passenger lift for easy access to the upper floor. All communal areas are on the ground floor including lounges, an activities room and toilets. There is a large conservatory at the back of the home which serves as the dining room. At the time of the inspection 24 people were living at the service.

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.

During a previous inspection in November 2015 concerns were identified relating to the Mental capacity Act 2005 (MCA) and in particular to the assessment of people’s capacity to make decisions. We made a recommendation. At this inspection we checked people’s care records for evidence that capacity was being assessed on a decision-specific basis in accordance with the MCA. We saw that improvements had been made to capacity assessments and they were no longer generic.

At the previous inspection we identified concerns relating to the submission of notifications to the Commission and the display of the ratings from an earlier inspection. At this inspection we looked at recent incidents and spoke with the registered manager regarding these matters. We saw that notifications had been submitted as required and that the ratings from the previous inspection were displayed.

People and their relatives told us that they felt the service provided at Cedar Grange was safe. We saw that staff were vigilant in monitoring safety and acting to protect people from harm.

Risk was appropriately assessed and recorded in care files. We saw examples of risk being regularly reviewed in conjunction with care plans and with the involvement of people, relatives and care staff.

Because of the design and layout of the building and the vulnerability of the people living at Cedar Grange, we were concerned about the effectiveness of emergency evacuation procedures. The instructions were clear, but did not indicate exactly where it was safe to move people to within the building in the event of a fire. We spoke with the registered manager and maintenance manager about this and they provided an updated set of instructions with greater detail within 24 hours.

Staff were recruited following safe procedures and deployed in sufficient numbers to provide safe, effective care.

Medicines were stored and administered in accordance with best practice guidance. Where issues had been identified through audits, they had been addressed appropriately.

The staff that we spoke with were positive about the training that was made available to them. We saw from the training matrix that staff had access to a wide range of training course which gave them the skills and knowledge to meet people’s needs.

We observed the lunchtime experience, looked at the menus and spoke with a chef at the service. Lunch was served in a well presented dining room and consisted of two sittings. People who required assistance were seated first so that staff could attend to their needs.

People were supported to maintain their health through regular contact with community-based healthcare professionals. The service had daily input from district nurses and GP’s and made use of a ‘Telemed’ service which gave access to healthcare professionals for consultation over a secure internet connection.

Cedar Grange had been adapted to meet the needs of people living with dementia. The service had a reminiscence room, music room and other de

We carried out an unannounced comprehensive inspection of this service on 9 and 10 June 2015 and identified two breaches of regulation in the ‘safe’ and ‘effective’ domains. The breaches of regulation were related to concerns we identified about the management of medicines and application of the principles of the Mental Capacity Act (2005). We asked the provider (owner) to take action to address these concerns.

In addition, we identified a minor concern within the ‘Responsive’ domain and made a recommendation for improving practice.

Following this comprehensive inspection the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 27 November 2015 to check that the provider had met the legal requirements identified in ‘safe’ and ‘effective’. We looked at whether the concern identified in the ‘responsive’ domain had been addressed. The ‘caring’ domain was not assessed at this inspection as it was rated ‘Good’ at the inspection in June 2015. We did not plan look specifically at the ‘well-led’ domain. It was rated as ‘requires improvement ‘in June 2015. To improve the rating to ‘good’ would require a longer term track record of consistent good practice. However, some issues were identified and these have been reported under ‘well-led’. You can read the report from our comprehensive inspection, by selecting the 'all reports' link for ‘Cedar Grange’ on our website at www.cqc.org.uk.

Located in a residential area of Southport and near to local facilities, Cedar Grange Ltd is a residential care home providing accommodation and personal care for up to 26 people living with dementia. Accommodation is provided over two floors with a passenger lift available for access to the upper floor. All shared areas are on the ground floor, including three lounge areas, a dining room and a large conservatory at the back of the home leading into a courtyard and garden.

Nineteen people were living at the home at the time of our inspection.

A registered manager was not in post at the time of our inspection. The manager had submitted an application to register with the Care Quality Commission (CQC). This was being processed at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found that improvements had been made in the areas we had concerns about and the previous breaches had been met.

Staff sought people’s consent before providing routine support or care. The staff team had received training in the Mental Capacity Act (2005). Mental capacity assessments were being conducted in a generic way and were not based on a decision the person needed support with making. This meant the home was not working with the principles of the Act. We made a recommendation regarding this.

Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority.

The way medicines were being managed had been reviewed and we found they were being managed in a safe way. They were administered from a trolley that was stored in a secure and dedicated medication room when not in use.

Risk assessments and care plans were in place for the people living at the home. These were individualised to the person and the care plans provided clear and concise information about how each person should be supported. Risk assessments and care plans were reviewed on a monthly basis or more frequently if needed. They were revised to reflect people’s changing needs.

Staff had received adult safeguarding training. We could see from the incident reporting records that appropriate safeguarding alerts were made to the Local Authority.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. We observed that there was sufficient numbers of staff on duty during the inspection. There was an unhurried and relaxed atmosphere in the home.

Staff received regular supervision and appraisal. Training records showed staff were up-to-date with the training they were required by the organisation to undertake for the job.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment and equipment. Individual plans were in place for the safe evacuation of people should an emergency occur.

People’s individual needs and preferences were respected by staff. They were supported to maintain optimum health and could access a range of external health care professionals when they needed to.

The menu was varied and we observed people enjoying their breakfast. People got plenty to eat and drink throughout the day.

Staff had a good understanding of people’s needs and their preferred routines. We observed positive and warm engagement between people living at the home and staff throughout the inspection.

A procedure was established for managing complaints. No formal complaints had been received within the last 12 months.

We noted during the inspection that CQC had not been notified of two recent safeguarding alerts made to the local authority. The manager sent these to CQC shortly after the inspection.

The ratings from the June 2015 were not displayed in accordance with the requirement to do this within 20 days of publication of a CQC rating. The manager advised that they had been displayed. It was likely the ratings were removed when the notice board was taken down for re-decoration.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

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?

We observed people who lived at the home being treated with dignity and respect. Safeguarding procedures were robust and staff members had received ongoing training in safeguarding awareness. This meant staff members were able to keep people safe and protect their welfare.

Systems were in place that dealt with any complaints effectively. Any incidents or accidents had been recorded appropriately and were discussed at regular meetings held for managers and staff members. This ensured that all staff learnt from such events with the aim of improving the quality of service provided to people living at the home.

We observed the care home to be clean and hygienic and all equipment and appliances in the home were checked and serviced regularly and so prevented putting people at unnecessary risk of harm or injury.

A Deprivation of Liberty Safeguard (DoLS) application was made in March, 2014. Although the provider had overlooked informing the Care Quality Commission, who monitor the use of DoLS, of the application, all other related requirements had been completed appropriately.

Is the service effective?

People living at the care home received a pre-admission assessment. As far as possible, people or their families were involved in the care planning process. We observed care plans were focused on the person`s individual wishes and preferences which reflected a person centred approach to providing care.

The layout of the care home allowed people who lived there to move around freely and safely. We were informed that signage and menus were being revised to meet people`s needs better. Picture menus had been introduced and picture signage was going to be used in other areas of the care home, for example bathrooms and toilets, which would help people living in the care home.

Is the service caring?

During our inspection we observed people who lived in the home being cared for, and supported by, staff members who were patient and helpful. One person said, "The staff are really kind - if you need anything they are there for you." A visitor said, "We are very happy with the service we receive here - we are always made welcome."

Staff members were knowledgeable about the needs and wishes of all people living at the home and support was delivered in a way that met those needs.

Is the service responsive?

We saw a record of complaints that had been received at the care home. We looked at how one complaint had been handled and could see it had been responded to appropriately in an open and timely manner. Consequently people and their families were assured that complaints were acted on positively and we observed action was taken when necessary.

Is the service well-led?

As part of a quality assurance system at the home, the provider arranged both internal and external audits. Any identified issues were addressed via an action plan without delay and, as a result, the service was continually improving.

The provider held regular meetings for staff members which ensured they were kept aware of their roles and responsibilities. Supervisions and appraisals were held for staff members which enabled them to raise any issues they had.

During the visit the atmosphere in the home appeared calm and relaxed. A number of the people living in the home were in one of the three lounge areas. People had a warm drink and appeared settled. We observed good interaction between staff and people who lived in the home.

We spent some time walking around the home and observed there had been a number of improvements to the environment. The home had new vinyl flooring on the ground floor and new carpet on the stairs and landing on the first floor. The communal rooms and areas were fresh and odour free. Low level lighting was now in place in the lounge areas and this helped create a comfortable and relaxed environment to live in.

Staff we spoke with confirmed that there were now consistently three care staff on duty during the day and night shifts. Staff absence was covered by the care manager and additional staff coming on duty as required. Staffing was discussed at staff meetings and quality meeting. Records confirmed this.

Kitchen staff were now on duty at all meal times to support care staff carry out their role and to provide people with choices at mealtimes. The manager told us they had changed the mealtime routine in the home to ensure people were observed and supported appropriately. The manager told us additional staff visited the home twice each week to assist with the social activities planned.

During tea time we observed interactions with staff were limited. We found the staff’s tone and manner were respectful, however interactions were mainly brief and task led. We observed staff were unable to observe and support people in a timely manner across the communal areas of the home.

We looked at the care records of six people who lived at the home and found they were organised and included assessments of people’s individual needs, risk assessments and personalised care plans.

We observed the home had appropriate protective equipment in place, such as gloves and aprons to minimise the risk of infection.

The home had three members of care staff on duty each day and three carers at night to support 25 people. Staff we spoke with informed us that staffing levels during the day had remained the same in spite of an increase in occupancy and dependencies since the last inspection in February 2013. At the time of that inspection 17 people lived at the home.

Due to the staffing levels on the day of the visit, we observed staff were unable to deliver the social activities which were on the home’s activity schedule.

We did not find evidence of an assessment of people’s dependency needs to help ensure the appropriate numbers of staff were on duty at different times of the day.

The home had records related to the running of the home which assisted in maintaining a safe environment for people and staff to live and work in.

We spent time with people living at the home during meal times and when they were in the lounge areas. We observed staff being attentive to their needs and their tone and manner was respectful and caring. We saw staff asking people’s views and checking to see if people needed support.

Care plans were based on people's assessment of need and provided staff with guidance about how to support the person. One person living in the home told us the care provided was good and that the staff helped them with appointments. We spoke with a family member who was actively involved with their relative’s care. They told us,” I have no concerns. My [relative] is well looked after.”

Records showed that the home worked well with external professionals to support the care they provided, including with GPs, psychiatry, district nursing and opticians.

We looked at three staff personnel files and found evidence of pre-employment checks and selection processes. The home had a four day induction programme in place to support new staff.

We saw a copy of the ‘service users handbook’ which contained information about how to make a complaint and included a copy of the home’s complaint form, statement of purpose and commitment about privacy, dignity and philosophy of care. A recent survey from 2012 showed a high level of overall satisfaction with care standards in the home.

We spoke with five people who live in the home and none of them raised any concerns about the way their medicines were handled.

Due to the different ways that the people living at Hope Cottage communicated, we were not able to directly ask them their views about the care and support they received. We did however meet with most of the people living there and spent time observing the support they received from staff.

We saw that people sitting in the various communal areas appeared comfortable and at ease with the staff. We observed staff sitting with them and taking time to help with their general care. For example assisting people from their wheelchair to a lounge chair.

We spoke with four people who live in the home and none of them raised any concerns about their medicines.

People living at Hope Cottage had dementia and were not able to directly give us their views about the support they received, so we used a specific way of observing care to help understand their experiences. We have taken the information we gathered during our observations into account in writing this report.

This unannounced inspection of Cedar Grange Ltd (previously Hope Cottage Limited) took place on 9 and 10 June 2015.

Located in a residential area of Southport and near to local facilities, Cedar Grange Ltd is a residential care home providing accommodation and personal care for up to 26 people living with dementia. Accommodation is provided over two floors with a passenger lift available for access to the upper floor. All shared areas are on the ground floor, including three lounge areas, a dining room and a large conservatory at the back of the home that leads into a courtyard and garden. Nineteen people were living at the home at the time of our inspection.

A manager for the home was registered with Care Quality Commission (CQC) but they had left the service and the provider (owner) was waiting for them to apply to deregister with CQC in order to register an alternative manager. A registered manager is a person who has registered with CQC 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.

Due to needs associated with memory loss not many people were able to verbally express whether they felt safe in the way staff supported them. We observed that people were comfortable and at ease with the staff. Visitors (mainly relatives of people living at the home) we spoke with expressed no concern about the safety of their relative. We observed that people living at the home confidently approached and engaged with staff throughout the inspection.

Staff had a good understanding of people’s needs and their preferred routines. We observed positive and warm engagement between people living at the home there and staff throughout the inspection.

Staff understood what adult abuse was and the action they should take to ensure actual or potential abuse was reported. Staff were aware of the whistle blowing policy and said they would not hesitate to use it.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. Staff and visitors we spoke with told us there was sufficient numbers of staff on duty at all times. We observed that people’s needs were met in a timely way.

A range of risk assessments had been undertaken for each person depending on their individual needs. Risk assessments and associated care plans were reviewed each month and modified to reflect people’s changing needs. The quality of the recorded care plans and care plan reviews was variable. We made a recommendation about this.

People living at the home were supported to maintain optimum health and could access a range of external health care professionals when they needed to. People enjoyed the food and they got plenty to eat and drink.

People received their medication at a time when they needed it. Systems were in place to ensure medicines were managed in a safe way. However, we found that controlled drugs were not stored securely and the temperatures of the medicine fridge were not routinely recorded. Controlled drugs are prescription medicines that have controls in place under the Misuse of Drugs Legislation. You can see what action we told the provider to take at the back of the full version of this report.

Staff told us they were well supported through the induction process, regular supervision and appraisal. The staff we spoke with said they were up-to-date with the training they were required by the organisation to undertake for the job.

The building had recently been significantly refurbished. The principles of a dementia-friendly environment had been taken into account with the refurbishment. The environment was clean, well-lit, airy and clutter free. Measures were in place to monitor the safety of the environment.

Staff’s understanding of the Mental Capacity Act (2005) was limited and some staff were unclear about how The Act applied in a care home setting. Although training was planned, none of the staff team had received training in mental capacity. Mental capacity assessments had been completed for people living at the home but these were general in nature and not decision-specific. You can see what action we told the provider to take at the back of the full version of this report.

The culture within the service was and open and transparent. Staff told us management was both approachable and supportive. They felt listened to and involved in the development of the home.

Opportunities were in place to address lessons learnt from the outcome of incidents, complaints and other investigations. Audits or checks to monitor the quality of care provided were in place and these were used to identify developments for the service.

A procedure was established for managing complaints. There were very few complaints recorded and those that had been received were managed in accordance with the procedure and to the satisfaction of the complainant.