About the service: The Cedars is a residential care home, providing personal care for up to 49 people. At the time of the inspection there were 40 people living at the home, some of whom were living with dementia. Accommodation was provided across two floors, with communal areas on the ground floor.

People’s experience of using this service:

At the previous inspection in November 2018, we rated the service as Requires Improvement. This was because although some improvements had been made, there were areas where further improvements were needed. At this inspection, we found many improvements had been made and areas where further improvements were needed, were identified by the management team. The service is now rated as Good overall.

Continued improvements were needed to ensure all care plans reflected people’s health needs and best interest decisions. However, there were more thorough care plan monitoring systems in place and there were some good examples of person-centred care planning.

We continued to receive mixed feedback about the food at the service. We saw that people had a choice of two different main meals at lunch time, and a range of lighter options in the evening. There were bowls of snack foods and a choice of drinks available in different areas of the home.

Work was taking place to create an open culture where everyone, including people, their relatives, and staff contributed to decisions about the service. This included identifying what everyone felt dignity in care meant.

People and their relatives had the opportunity to attend meetings to share their views. We saw staff asking people how they were and spending time with them. Relatives were welcomed to join people in activities or to visit at any time. People had access to different communal areas including quieter lounges, a large dining area, and spaces for activities.

There was a varied social programme of activities and events. Good community relationships had been formed, and there was support from volunteers.

Medicines continued to be managed safely. Records were up to date and monitored to ensure that people received their medicines and creams as prescribed.

The home was clean, tidy and free from bad odours throughout. Some areas had been redecorated and there were new carpets throughout the home. There were hand rails to help people move around the home safely.

People were supported by staff who received a range of training, including training in dignity and supporting people living with dementia. Staff received supervision conversations with their senior and attended staff team meetings.

People, their relatives and staff felt more supported by the home management team. We received positive feedback about how visible the home manager was.

Rating at last inspection: Requires Improvement (Report published 6 February 2019)

Why we inspected: Because the home had previously been repeatedly rated as Requires Improvement, we needed to ensure that improvements had been made.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

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 Cedars provides accommodation and personal care for up to 49 older people. At the time of our inspection 44 people were living at the home, and three of those people were receiving care and treatment in hospital. Bedrooms were situated across two floors, with communal bathrooms throughout the service. People living on both floors shared the ground floor dining room and lounge areas.

The inspection took place on 27 and 28 November and was unannounced.

At the time of the inspection there were two registered managers. One of the registered managers was in the process of de-registering, due to a change in role; the other was on a period of extended leave. 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.

Overseeing the management of the service on an interim basis was a peripatetic manager. They were supported by the de-registering manager who had been appointed as the head of care. There was also a registered manager from the same provider based at the service as a supporting manager, one day per week. We met with the peripatetic manager, the head of care, the supporting manager, and the area operations manager during the inspection.

Most people and their relatives we spoke with were unsure who was leading the service.

Care plans for people with behaviours that staff found challenging to support were not detailed enough. The plans did not explain when staff should intervene in the person’s best interests. Staff did not follow the support plans and their interventions had not been reviewed to ascertain if they were the least restrictive options.

Where people displayed behaviours that staff found challenging, these were not recorded to identify if there were any patterns or trends in their behaviours. This meant that changes in behaviours were not being monitored.

The staffing numbers were decided using a dependency calculation tool, giving an expected number of staff and the lowest number that they could operate with. We saw that although the expected staffing number for night shifts was to have four members of staff on duty, frequently there were only three. We were told by different members of staff that one person required three people to support them with their personal care at one time. This left people at risk of not receiving support in a timely manner at night.

Some people and their relatives told us that they were not always able to have a bath or shower, or that their family member appeared to have gone for a long time without one. We checked the temperature records in the bathrooms, which should be completed each time a person has been supported to bathe or shower. Only 11 different people had received a bath or shower, according to the temperature records, throughout the four weeks prior to the inspection. Based on staff feedback and records observed, it was unclear if this was an accurate picture of the number of people supported, or if safety records were not always being completed.

At times, people’s dignity was not promoted. We saw people being supported with transfers using hoists. But, staff did not use the protective cover that supported people wearing skirts to maintain their dignity. Staff told us they knew why the cover was there, but they were not sure why some staff did not use it.

Activities were well attended and there was time allocated for one to one sessions, to support people at risk of social isolation. We saw festive activities were taking plac

The Cedars is a 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 service can provide accommodation and personal care for up to 49 older people at this location. At the time of our inspection there were 39 people living in the home, however three of these people were in hospital. The inspection took place on 6 and 15 March 2018 and was unannounced.

At the inspection on January 2016 we asked the provider to take action in response to our findings. A planned inspection took place in March 2017 to follow up on the concerns found at the previous visit. At this visit the service received a further rating of requires improvement and where we found breaches of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to risk assessments not in place or reviewed within designated timeframes. There was ineffective management of people’s behaviours that challenged and insufficient staff to respond to people’s needs. Records were not monitored correctly or accurately completed.

We took enforcement action against the provider and imposed a positive condition on the registration of this location. The service submitted a monthly improvement report to ensure that staffing, training and records are being monitored, audited and maintained in order to provide safe and effective care. However the action plan was not always consistent with the findings we found at this inspection.

At this inspection we found that the service had met one of the previous breaches identified and part of another breach. The service remained in breach of three Regulations, and were in further breach of other Regulations. This is the third consecutive time that this service has been rated as requires improvement and we are considering what further action will be taken in response. We met with this provider to discuss these concerns and seek assurance about the action they would take. The positive condition imposed on the registration for this location will remain in place until we re-inspect again shortly.

The registered manager was absent from the service and on a period of planned leave. 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 head of care had stepped up into the role of acting manager since February 2018 and was going through the process to become a jointly registered manager for this period of time. The acting manager and area operations manager were both present and available throughout our inspection.

Medicines were not always managed safely. People with prescribed time specific medicines did not always receive these on time. Stock levels of some medicines were not regularly checked. The service was in breach of this Regulation.

Risk assessments did not always contain enough detail to minimise the risk. Examples of unsafe practice were observed. The recording of people’s behaviour that at times challenged was not consistent or appropriate. The service remains in breach of this Regulation.

Although the levels of staffing were sufficient according to the provider’s dependency tool, the deployment of staff was not always managed efficiently. The service remains in breach of this Regulation.

We observed interactions where staff did not always act respectfully in regard to the people they supported or maintained their dignity. The service was in breach of this Regulation.

The service continued to have ineffective recording in care plans and monitoring records. The lack of appropriate recording meant that risks to

The Cedars provides accommodation and personal care for up to 49 older people. At the time of our inspection there were 32 people living in the home and two people in hospital. The inspection took place on 14 and 15 March 2017 and was unannounced.

A registered manager was not in post when we inspected 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. A manager from one of the provider’s other homes was managing the service and this manager has since become the registered manager for the service. The manager was present and approachable throughout our inspection.

At our previous inspection the home received a rating of requires improvement and were in breach of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection some improvements had been made but we found that the home had a repeated breach and further breaches of the regulation were identified. You can see what action we told the provider to take at the back of the full version of the report. We are taking further action in relation to this provider and full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Risk assessments had not always been put in place where there was an identified need. We saw some risk assessments were not being reviewed within the designated time frames to ensure they remained in line with people’s changing needs.

The home did not have effective measures in place to be consistent in their management of behaviours that challenged. Staff had not received training in this.

The recruitment of staff had remained inconsistent since the last inspection which had impacted on the care people received and the pressures staff felt.

Staff had a good understanding of how to identify safeguarding concerns and act on them to protect people. People we spoke with told us they felt safe living at The Cedars commenting “If I press the buzzer I don’t have to wait too long before someone will come and answer it. I do feel safe knowing there is help available if I need it.”

Staff had not always been given the opportunity to attend training and supervisions in order to develop and maintain their skills and receive support. The manager was in the process of addressing this.

The home had not always obtained the appropriate consent before taking decisions on behalf of people to ensure care was given in line with their preferences.

People’s healthcare needs were regularly monitored. There was evidence of regular consultations with health care professionals where needed and we saw staff seeking advice when needed.

People spoke positively about staff and the care they received. We saw that people were comfortable in the presence of staff and had developed caring relationships. One person told us “The staff are very kind to me, they look after me well.”

The service had remained in breach of the Regulation for ineffective recording in care plans and monitoring records. There was often inconsistent or conflicting information which made it hard to ascertain a person's most current needs.

The service had experienced a period of instability and this had impacted on people, their relatives and staff. A manager from one of the provider’s other homes was providing management support to the home and since we visited the service has become the registered manager. The manager was working hard to address areas of concern she had identified and an action plan was in place. Staff spoke positively about the support they were now receiving and told us the manager was approachable and available should they need to

The Cedars provides accommodation and personal care for up to 49 older people. At the time of our inspection there were 38 people living in the home, 2 of whom were in hospital.

This inspection was unannounced. There was a registered manager in post when we inspected 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. The manager was accessible and approachable. Staff, people who used the service and relatives felt able to speak with the manager and provided feedback on the service.

A previous safeguarding had been raised in relation to managing pressure care at the home. An independent tissue specialist nurse attended the inspection and explored this area in depth. The findings showed preventative measures had been put in place and action taken to protect people from pressure sores. We found staff to be very knowledgeable on pressure care and people had access to the correct equipment to help minimise the risk of pressure damage.

Recording was not always completed correctly. The recording in people’s MAR’s (medicine administration records) for supplement drinks and the rotation of medicine patches was not completed. This meant people were at risk of not receiving their prescribed medicines in line with the GP recommendations. Fluid charts in place to monitor people’s liquid intake, had not been totalled correctly. This meant action that needed to be taken could be delayed as the monitoring system was not being used effectively to detect concerns. Care plan recording around people’s mobility and dependency needs showed inconsistencies where the old paperwork had been left in the folders. The most relevant information was placed at the back making it hard to identify a person’s current needs. This was a breach of the regulations.

People had a high number of falls. Whilst action around these falls had been taken we identified further precautions that needed addressing. The lighting in people’s bedrooms was inadequate, posing a potential risk for people with visual impairments. Equipment such as hoists and wheelchairs were repeatedly left in narrow corridors or seating areas causing a hazard for people unsteady on their feet. This was a breach of the regulations.

Where there was challenging behaviour displayed from people, the home would work to find a more suitable placement that could meet this person’s needs. Staff told us they were currently assisting one person who displayed aggressive behaviour. Three staff members would often attend this person and staff had not received appropriate training around safe method of restraint. This meant that this person and staff were potentially at risk from unsafe practices and a lack of knowledge. This was a breach of the regulation.

These breaches can be read about in more detail in the full version of the report and the action we have told the provider to take.

The service had a strong commitment to supporting people and their relatives at the end of their life. The management team were determined that people should remain in the home being cared for by the staff they knew unless the home could not provide the level of care someone might need at end of life.

People told us they felt safe living at The Cedars and they were well cared for. The provider had systems in place to manage risk and protect people from abuse. Staff had a good understanding of safeguarding and whistle-blowing procedures. They also knew how to report concerns and had confidence in the manager that these would be fully investigated to ensure people were protected.

The home was piloting the new care certificate induction. New starters told us their induction prepared them well for their role and they were able to shadow ex

We spoke with four people who lived in the home about the care they received. They all stated that their dignity and privacy was respected and nearly all the staff were kind and caring.

They liked having their own rooms. One person stated that “it’s my home and staff treat it that way.” Another said that “I like the freedom I have here and can do what I want”.

One person had kept their own cat there for the last four years. They told us that staff had often helped with looking after it when they could not cope and they were very grateful to them.

People told us they enjoyed the activities that were provided and that they had the choice of whether to participate or not. Some people said they preferred to stay in their rooms and that they enjoyed the privacy this gave them.

People told us they could choose how they spent their days. One person told us they preferred to spend their time in their room and were glad staff respected this. People told us they liked living in the home. One person said “it’s very nice, friendly”. People we spoke with were appreciative of the staff. One person told us about the “very good staff”. A relative commented on the provider saying the felt they had “high standards” and wished to “keep them up”. Staff told us they liked working in the home. One care worker said “I love it” about their role. Another member of staff told us “we’ve done it all” about their training.

Staff did not always support people’s privacy and dignity in all areas, for example discussing people’s individual needs in private. We observed people were not helped as they needed to be in engaging with life in the home. Very frail people and people with complex care needs did not have clear written information about how their needs were to be met and different staff told us different things about meeting their needs. Staff were not following principals of infection control, particularly in relation to management of laundry. The provider has identified areas for action to improve quality of care, but certain areas had not been addressed, for example following guidelines relating to safe bath water temperatures.

People told us that staff had respected choices they had made and were considerate of their needs. We looked at people's care plans and supporting documents that had detailed their needs and supported choices they had made.

We found that people were involved in menu planning and enjoyed a varied diet that met their individual needs.

People told us they were happy living in the home and were mostly complimentary of the services provided and of the staff team. Comments included, “when I first came here I was sad, but now I am ok as it is pretty good”. “Staff are all very nice”, “some staff will only do what is needed”. We have told the provider that some people were concerned that there was not always enough staff around during busier times of the day, such as meal times.

The provider had ensured staff received appropriate professional development and support to safeguard and deliver care to the people who lived in the home.

We found that people and their relatives had opportunities to contribute their views about the quality of the service. The provider had systems for monitoring services provided.