The Cedars Nursing Home 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 Cedars accommodates up to 62 people in one adapted building. At the time of our inspection 45 people were living at the home.

This inspection took place on 20 September 2018 and was unannounced. We returned on 21 September 2018 to complete the inspection.

The service did not have 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. A manager was in post and they had submitted an application to be registered with us.

The home did not have effective systems to safely manage people’s medicines. People did not always receive the medicine they had been prescribed and staff did not keep accurate records of the medicines they had administered.

Risks people faced were not always effectively managed. Information in risk assessments was not always up to date and plans were not always amended following changes to the risks people faced. This increased the risk that staff would not have the information and guidance they needed to follow safe practice.

The registered person had not ensured everyone using the service had an accurate, up to date care plan, which set out how their care and treatment needs should be met. Care plans did not always contain detailed information about how to meet people’s needs in the way that they wanted.

The provider had failed to ensure the home has been well-led since 2014. We have completed four comprehensive inspections since July 2014. At each of these inspections we have assessed the service to either be in breach of regulations or require improvement to ensure people received a good service. Action has been taken to address specific issues we have identified, but subsequent inspections have identified further areas of concern.

Systems to track incidents and accidents and plan actions to minimise the risk of them happening again were in place, but had not been used effectively by the management team. Quality assurance systems had identified shortfalls in the service, but the service did not have effective systems to plan and achieve the improvements that were necessary.

People who used the service were generally positive about the care they received and praised the quality of the staff and management. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy and responded to requests for assistance.

People told us they felt safe when receiving care. Systems were in place to protect people from abuse and harm and staff knew how to use them.

Sufficient staff were deployed to meet people’s needs safely. People’s needs were kept under review and staffing levels had been changed where necessary.

People had regular meetings to provide feedback about their care and there was an effective complaints procedure. People were supported to take part in social activities that were suitable to their specific needs and wishes.

Staff demonstrated a good understanding of their role and responsibilities.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The Cedars Nursing Home is a care home which provides accommodation and nursing care for up to 62 older people. At the time of our inspection 44 people were resident at the home.

This inspection took place on 24 May 2017 and was unannounced. We returned on 25 May 2017 to complete the inspection.

At the last comprehensive inspection in January 2016 we identified that the service had taken action to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, further work was required to ensure these improvements were embedded in practice and sustained. During this inspection we found that the provider had made further improvements in most aspects of the service provided to people. However, staff did not always communicate in ways that demonstrated respect to people and the service did not have a registered manager in post.

Staff did not always work in ways that were person centred or treated people with dignity and respect. During the inspection we observed staff talking over people who use the service, staff providing support to people without speaking to them or explaining what they were doing and staff using language that did not demonstrate respect for people.

Feedback from people who use the service about the approach of staff was mixed. One person said that they were “Very happy” living at The Cedars and added “The staff are lovely.” However another said “Some (staff) stand around talking to each other over me.” One person’s relative felt that there was a lack of social interaction and support between staff and their relative, particularly at meal times. “They come in, just push the plate at her and then their off. No offer of help.”

We also saw some good interactions from staff, where they worked in ways that were respectful of people and explained what was happening.

The service did not have a registered manager in post. Following the last inspection in January 2016, the provider recruited a new registered manager, but they left their post at the service in April 2017. The regional manager informed us a new manager had been recruited, but they left the service after a few weeks in post. The provider had a condition of registration that a registered manager must be in post at The Cedars and was therefore in breach of their conditions of registration at the time of the inspection. The regional support manager told us she intended to submit an application to register as the manager of the service until a new manager was recruited and registered. We will monitor this and will consider further enforcement action if the service continues to operate without a registered manager.

People said they felt safe living at The Cedars Nursing Home. Comments included, “Oh yes very safe. I have a laugh with the carers; they are very nice”, “Yes it’s alright. I think I have fallen on my feet here. The best thing is that I feel secure” and “It’s ok, I’m happy here; they are nice people. I feel safe here”. Systems were in place to protect people from abuse and harm and staff knew their responsibilities to protect people and keep them safe from harm.

Staff understood the needs of the people they were providing care for. Staff received a thorough induction when they started working at the home. They demonstrated a good understanding of their role and responsibilities. Staff had completed training to ensure the care and support provided to people was safe and effective to meet their needs.

The provider regularly assessed and monitored the quality of care provided at The Cedars Nursing Home. The information from these assessments was used to plan improvements to the service provided.

The Cedars Nursing Home is a care home which provides accommodation and nursing care for up to 62 older people. At the time of our inspection 39 people were resident at the home.

This inspection took place on 12 January 2016 and was unannounced. We returned on 13 January 2016 to complete the inspection.

At the last comprehensive inspection in June 2015 we identified the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were not enough staff to meet people’s needs, medicines were not always managed safely, the infection control procedures were not always followed and the service was not well managed. We served warning notices to the provider as a result of the concerns we identified. We completed a focussed inspection in August 2015 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found the provider had sustained these immediate improvements, but further work was needed for people to receive a consistently good service.

Staffing levels were safe, but some people felt additional staff would help them receive a more personalised service. Staff were available to provide support to people when needed, including support for people to eat, drink and move around the home safely. Call bells were answered promptly and staff responded to verbal requests for assistance from people.

Most people told us they thought there were sufficient staff available. Comments included, “They come quickly when I ring”, “There are no long waits” and “Yes, I think there are enough staff”. Two people expressed concern about staffing levels, citing the time it took to answer call bells and the time they were supported to get into bed in the evening.

Relatives told us they felt the staffing levels were usually suitable to meet people’s needs. Comments included, “Having less people in the home means staff have more time to sit and talk to people” and “There are generally enough staff to meet (my relative’s) needs, but maybe having one more (on the wing for people with dementia) would be better”.

During this inspection we found the improvements to risk management systems had been maintained, although some further work was needed to ensure staff were recording and analysing incidents more effectively.

Medicines were being managed safely and infection control procedures were being followed, which helped to minimise the risk of cross infection.

Staff understood their responsibilities under the Mental Capacity Act 2005 and the action they needed to take if people did not have capacity to consent to their care.

People’s opinion of the effectiveness of the care and support they received varied. When asked whether staff supported them well one person replied, “They try to”. Another person said, “Some are good and some are just OK”. A third person said, “It’s very hit and miss. All very well meant. They have good intentions but not always the ability. Most of the nurses are very good”.

Although most staff had completed training in person centred care and care of people who have dementia, we observed some interactions in which this was not put into practice. This included completing tasks without interaction with the person and not listening to people's responses to questions. Other staff demonstrated they had understood the training they had completed. We observed staff interacting with people in a way that demonstrated a good understanding of their needs and a warmth towards them. The regional manager acknowledged that more work was required to embed the training into day to day practice for some staff.

At this inspection we found there had been an improvement in the information set out in people’s care plans. People’s records contained care plans relating to their specific needs and there was evidence the plans were updated when people’s needs changed. Some people told us they were i

People said the home met their needs and they could make choices. One person told us “of course I can get up and go to bed when I want to.” Another person described how they were “very pleased” with the care they received. A relative said the staff were “very kind and sweet to my [parent].”

We saw staff looked after people who had dementia in an appropriate way. People we met with on the dementia and other units were calm and staff treated them with respect.

Frail people who needed support from staff were given the care they needed. This included reducing risks to them from pressure ulceration and dehydration. Records, including care plans, were clear and reflected people’s needs.

Medicines were administered to people in a caring and sensitive manner. Full records of medications were maintained. Medications were stored in a safe way.

A range of equipment was provided to meet people’s nursing and care needs. A member of staff told us “we’ve all the equipment we need.” There were systems to report faulty equipment and ensure it was taken out of use until it was safe.

We visited The Cedars on 11 October 2012 to see how record keeping had been improved since our visit in May 2012. We had asked the provider to tell us what actions they were taking to ensure that how they planned and recorded people’s care was accurate and safe. They sent us an action plan. They told us all care plans would be revised and updated. We found this was the case. Care plans gave staff detailed guidance on understanding and meeting people’s individual needs. The records that staff kept showed that people were receiving care in the way that it was planned.

The provider told us they were ensuring registered nurses understood the importance of good quality, accurate records. We spoke with three registered nurses, who confirmed they had received appropriate supervisory guidance.

The provider told us they were introducing a regular audit of care plans. We saw evidence of these, although it was early to assess their effectiveness. There had been a change of temporary manager of the home. We were told this had impacted on the introduction of the audits. A permanent manager was due to join the home in October 2012.

We spoke with three care assistants. They told us care plans were accessible and helpful. What staff told us, and what we observed of people’s needs, matched with what the care plans told us. A visiting GP told us the registered nurses found information from the home’s records quickly when necessary, and the quality of information was good.

We visited The Cedars Nursing Home on 15 May 2012. We met and talked to a number of people using the service and the staff on duty.

We used a number of different methods such as talking to people and observing their care to help us understand the experiences of people using the service, because some of the people using the services had a clinical diagnosis of dementia, or were experiencing the symptoms of dementia.

People told us “all staff are very helpful, they’re very good”, “I have a very, very nice view”, “yes, I do feel safe here” and “I’m finding it alright so far”.

We talked to members of staff who demonstrated they had a good a good knowledge of people’s needs. We saw staff were patient and polite with people.

We saw people looked relaxed and comfortable in their environment. Staff involved people in their conversations and activities were provided. People could choose to join in or not.

Staff told us things had improved at the home. They said the manager was fair and approachable.

At our last inspection we set three improvement actions and three compliance actions. The previous manager has left the home, since that inspection. The new manager had only been in post for two weeks when we visited. The provider submitted an action plan detailing the progress made. The home has made progress in most areas although further improvement is required for the home to be compliant with Regulation 21 (Records). We have therefore used our discretion and made a repeat compliance action for this regulation.

People and their supporters told us they were treated well by the staff at The Cedars. One relative commented that their family member was always clean and tidy and appeared to be happy living at the home. People felt their care needs were being met. They said they were generally happy with the food they received although some people felt the food was not cooked to their liking.

Whilst people were happy with the care they received not all staff consistently maintained people’s privacy and dignity. The majority of people were well presented, however one person did not receive support with their personal care routines in a timely manner. Records did not reflect the level of care necessary for people’s health, safety and welfare. Care charts and people’s daily records did not show the support people received. It was therefore not possible to see whether people’s needs were effectively being met.

At the comprehensive inspection of this service in June 2015 we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with three warning notices and two requirements stating that they must take action. We shared our concerns with the local authority safeguarding and commissioning teams.

This inspection was carried out to assess whether the provider had taken action to meet the three warning notices we issued. We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notices have been sustained, to assess whether action has been taken in relation to the two requirements and provide an overall quality rating for the service.

This report only covers our findings in relation to the warning notices we issued and we have not changed the ratings since the inspection in June 2015. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Cedars Nursing Home on our website at www.cqc.org.uk.

At this inspection we found that the provider had taken action to address the issues highlighted in the warning notices. More staff had been provided and there were better systems to manage staff absence and ensure shifts were covered. People said staff responded promptly when they used their call bell and were able to provide them with the care they needed. Relatives we spoke with also felt there were sufficient staff available in the home. One relative commented that they had been "very happy with the action taken since the last inspection - there are more staff available and they have been excellent". We observed that staff responded promptly to meet people's needs.

Risks people faced were being effectively assessed and managed. Staff had clear information about the support people needed. They demonstrated a good understanding of people's needs and the support that was required to keep people safe.

Medicines were being stored within the recommended temperature range and systems for ensuring cream medicines were applied correctly had been improved. Records were being kept of medicines staff had administered to people.

The manager and regional manager had developed a comprehensive action plan to address the warning notices and other requirements in the inspection report where they were found to be in breach of regulations. We saw that this plan was being regularly updated and amended to reflect the progress made with improving the service. Feedback was obtained through meetings with people who use the service, their relatives and staff. The meetings were used to explain the actions they were taking and the improvements they wanted to achieve.