This inspection took place on 18 January 2019 and was unannounced. At the last inspection completed on 19 and 20 October 2017 we rated the service Requires Improvement.

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.

We completed an unannounced inspection at The Cedars on 19 and 20 October 2017. At the last inspection on 09 November 2017, we found a breach in regulations because people were not consistently treated with dignity and respect. We asked the provider to take action to make improvements. At this inspection we found that there had been some improvements in this area. However, we identified further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as we could not be assured that people received safe care and treatment and improvements were needed to the way the service was managed. You can see what action we told the provider to take at the back of the full version of the report.

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

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 sta

We inspected this service on 15 April 2015. This was an unannounced inspection.

The service was registered to provide accommodation and nursing care for up to 42 people. People who used the service were living with dementia and required help with personal care.

Our last inspection took place on 17 April 2014 where we found the service to be compliant with the five outcomes we inspected.

The service had 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.

People’s safety risks were identified and reviewed; staff were attentive to the needs of people and promoted their safety. Medicines were managed safely.

Representatives of people who used the service felt that there was not always enough staff around at busy times of the day.

Staff received regular training that provided them with the knowledge and skills to meet people’s needs.

People’s health and wellbeing needs were monitored and people were supported to attend health appointments as required. People could access suitable amounts of food and drink that met their individual preferences.

Staff sought people’s consent before they provided care and support. However, some people who used the service were unable to make certain decisions about their care. In these circumstances the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were being followed.

People were treated with kindness, compassion and respect and staff promoted people’s right to privacy. Staff helped people to make choices about their care by giving them the information they needed to do this.

People and/or their representatives were involved in the assessment and review of their care. People were encouraged to participate in leisure and social based activities that were important to them.

Complaints and concerns which had been raised by people’s representatives had not always been managed in accordance with the provider’s complaints policy. The provider had not always ensured that improvements were implemented to improve the care people received as a result of the concerns and complaints raised.

The provider had a system in place to monitor the quality of care to ensure standards were met and maintained. This system had not always been effective in bringing about improvements. People’s feedback was sought but action was not always implemented to improve the care.

We visited ‘The Cedars’ on a planned unannounced inspection. We were supported throughout the inspection by the manager. At our previous inspection we had concerns that people’s care and welfare needs were not always met. The service had sent us an action plan telling us how they planned to improve. We looked to see if the improvements had been made and to answer the five key questions.

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.

The name ‘Rebecca Whitehouse’ appears on our report as being a registered manager at the home. At the time of our inspection this person was not the registered manager of the service. We have requested that the provider addresses this to ensure the correct details are held on our register.

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.

We carried out this inspection to check on the care and welfare of people who used the service as part of our planned schedule of inspections. The inspection was unannounced which meant the provider and the staff did not know we were visiting.

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.

We visited The Cedars to check compliance with the areas of concerns we had identified at our previous visit of 19 August 2011. Since our last visit the provider has sent us an improvement plan detailing the action they have taken to ensure that they comply.

During our visit we looked at the care records of four people using the service to check that the service was including people in important decisions about their well being and ensuring that regular reviews were undertaken.

We checked that medication systems had been reviewed to ensure that people using the service received medication when they were prescribed it, and safely. We also looked at four medication administration records.

We looked at staff rotas and spoke to staff about staffing levels. We observed staff interactions with people using the service and spoke to them about the support people received.

We saw that monitoring of the quality of the service had taken place, with evidence that the outcomes were being shared with people using the service.

We spoke to eight people using the service and two relatives during our visit undertaken on the 19 August 2011. People told us, "Staff are very good at this home and also manage to have a laugh with us at the same time." Another said, "I have my own room and can lock the door if I want to, staff help me to keep it clean."

"I love sitting in the garden watching the world going by."

One relative said, "I have been welcomed and encouraged to be as involved as I want to be in the life of my relative. I visit at all times of the day and there are no restrictions to this. I find that people using the service are supported appropriately and where they can make choices they are supported to do so."

Another said, "We were looking for a home for our relative and just called in one day, we've been very impressed with the service they provide. If we've had any concerns, we've felt able to approach staff and management and they have always responded positively."

We were told that people had lots to do and enjoyed the activities they were offered, including day trips, gardening, craft activities, exercise and music sessions. One person said, "I love the garden and some people enjoy gardening." We observed people chatting to one another, listening to music and having a sing a long with a karaoke machine. We saw photographs from a recent day trip displayed in the home and details of other activities and events, including a summer party arranged for the day after our visit.

People and their relatives told us the food they received was of a high standard with plenty of choices and always well presented. One relative said, "There's always a good range of food provided, people always seem to be eating." Another said, "I always visit at mealtimes and have never had any concerns about the quality, choice or quantity of food."

People and relatives told us they had good, friendly relationships with the staff, “Very good and lovely staff”. A relative said, "I find the staff are approachable and treat people with respect." Another relative said, "The staff sometimes seem a bit busy, but they will always take time to chat or answer any queries we may have."

We were also told that people had access to health professionals when needed including GPs, district nurses, opticians and chiropodist.