The inspection took place on 16 July 2018 and was unannounced. This meant the service did not know we would be visiting. We carried out a further announced visit to the service on 18 July 2018 to complete the inspection.

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

The Cedars is a large adapted Victorian property located in the Bowdon area of Trafford, Greater Manchester. Accommodation is provided over several different levels, accessed by either a passenger lift or stairs. Rooms are mainly single en-suite with some shared rooms being available.

The service is registered with CQC to accommodate up to 34 people and at the time of this inspection, 30 people were accommodated, the majority of whom were living dementia or memory problems.

We last inspected The Cedars in April 2016. At that time, we rated the service ‘Good’ overall. This inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury and subsequently died. This incident is subject to an ongoing investigation and as a result this inspection did not examine the specific circumstances of the incident. However, initial enquiries carried out by CQC regarding the incident indicated potential concerns about the risks associated with communal outside spaces, risk of falls and the management of accidents and incidents. This inspection examined those risks.

At this inspection we identified three breaches of regulations related to risk assessment, buildings and premises, and governance. We have also made a recommendation concerning equality, diversity and human rights.

This overall rating is now ‘Requires Improvement.' You can see what action we have asked the provider to take at the back of the full report.

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 2008 and associated Regulations about how the service is run.

We found the service had failed to pay due regard to guidance published by the Health and Safety Executive in 2014 concerning the management of health and safety in care homes. Environmental risk assessments did not appropriately assess and mitigate risks associated with people who used the service accessing the communal outside space whilst unsupervised.

The majority of people who used the service lived with dementia or memory problems but we found the environment within service was not dementia friendly. This contributed to people being disoriented and unable to navigate their way around the home independently.

The service continued to operative effective systems and procedures which sought to protect people from abuse. Staff could describe the signs and behaviours they would look out for that would alert them to the possible consequence of abuse.

Medicines were ordered, stored, administered and disposed of safely.

Feedback from people who used the service and their visiting relatives remained positive about the quality of food and drink on offer. Food was freshly prepared and a variety of choices were offered.

Before a person moved into The Cedars, a pre-admission assessment was completed which sought to ensure the service could meet the needs of potential new users of the service, and to ensure that any potential new admission did not negatively impact on the needs of existing people who used the service.

The routine day-to-day physical health needs of people who used the service continued to be met. People had regular access to community based health services s

We undertook an inspection of The Cedars 5 and 7 April 2016. The first day of inspection was unannounced which meant the provider did not know we were coming.

We last carried out an inspection at The Cedars in 17 September 2014. We found the service was fully complaint in all five standards we inspected at that time and was meeting legal requirements.

The Cedars provides residential accommodation with personal care for up to 34 older people and people living with dementia.

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

Staff were confident in describing the different kinds of abuse and the signs and symptoms that would suggest a person they supported might be at risk of abuse. They knew what action to take to safeguard people from harm.

A robust system was in place to identify and assess the risks associated with providing care and support. People’s support plans and risk assessments contained personalised information about an individual’s needs and provided guidance for staff as to the support people needed. A relative told us and care records confirmed, that risks had been discussed with them and actions agreed to keep people safe from accidental harm.

People who used this service received safe care and support from a trained and skilled team of staff. The induction of new staff and on going training of others was robust and staff told us they received regular support from the registered manager.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made and was aware of the principles of the Mental Capacity Act 2005. People who were subject to DoLS had their rights respected and the home operated within the legal framework of the Act.

People, relatives and other healthcare professionals involved with the service said that the support staff were caring. On the day of our visits we saw people looked well cared for. There was a relaxed atmosphere in the home. We saw staff speaking calmly and respectfully to people who used the service. Staff demonstrated they knew people’s individual preferences and what they needed to do to meet people’s care needs. The people we spoke with who were using the service, and visiting relatives, told us they were happy with the care provided.

People’s care plans contained information about their likes, dislikes and personalities, and were very much person-centred. They contained details about how people liked to be supported in all aspects of their care.

During our visit we saw examples of staff treating people with respect and dignity. Staff promoted people’s independence by giving them choices. People using the service and their relatives were consulted and involved in assessments, care planning and the development of the service.

There were enough staff on duty to meet people’s support needs and to provide activities for them. People’s access to activities was very good; we saw that people were supported to get out and about in the community. People were encouraged to maintain relationships that were important to them and the service actively involved and welcomed family members to events held at the home.

Staff told us that they felt supported by the registered manager. Formal supervisions and annual appraisals took place and staff we spoke with felt valued and listened to. Regular team meetings were also held and staff were able to raise any issues or concerns at these meetings. Staff were proud to work in the service.

The registered manager had developed a

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 looked at the storage of medication at the care home and found it was kept secure at all times. The medication cabinet was locked when not in use and was also secured to a permanent wall.

Emergency procedures were in place at Cedars Rest Home which helped ensure the safety of people who used the service. The staff members we spoke with were aware of their roles and responsibilities in the event of a fire.

Deprivation of Liberty Safeguards (DoLS) become important when a person is judged to lack the capacity to make an informed decision related to their care and treatment. The provider told us no applications for DoLS authorisations had been made but knew the procedure to be followed if an application needed to be made. On the day of our inspection, no person who used the service was subject to a DoLS.

Is the service effective?

When a person was admitted to the home, a further assessment took place that confirmed the choices people had made. This helped ensure people understood the care and support available to them.

People who used the service were supported to keep involved in the local community. One person we spoke with told us, "I like to go to church at the weekend. It`s something I enjoy doing." One staff member told us lay people also attended the home at regular intervals and conducted a service for all denominations to attend if they so wished.

Is the service caring?

We spent time in communal areas during our inspection. There was a calm and relaxed atmosphere and we saw staff who interacted and supported people in a patient, unhurried manner. This included assisting people with limited mobility between rooms.

We spoke with two people who used the service and two family members who were visiting. One person told us, "I am very happy here. The staff are always there for you if you need them." Another person told us, "Oh yes, we are well cared for and the food, I think, is lovely."

Is the service responsive?

General Practitioner and professional visits and appointments were recorded. The registered manager told us, "We have a really good relationship with the professionals who come here." This meant people received care and support when they needed it.

A complaints procedure was seen in the provider`s policies and procedures manual. A copy was also given to people on admission. This formed part of the service user handbook which was present in people`s rooms. This helped ensure people knew how to make a complaint if necessary.

Is the service well led?

The provider had procedures in place to monitor the quality of service being provided to people who used the service at the Cedars Rest Home. We saw records for both internal and external audits that had been completed. These included, monthly and annual infection control and medication audits.

The registered manager told us one to one meetings were held with residents and family members several times a year. We were told, "I find they work better because some people don`t like speaking out in a group." The manager told us the families were contacted and arrangements were made to suit them for a meeting.

The families we spoke to during our visit said they were kept fully informed of any changes to the care and support needs of their relative and felt confident that the needs of their relatives were being met.

We found that the care plans were comprehensive and person centred and aimed to promote the independence of the residents. We saw evidence of this with people being supported to walk as independently as possible with the use of equipment which belonged to them.

One of the areas we wanted to look at was around activities. This is because we had received an anonymous complaint regarding lack of activity and stimulation, particularly for those people who experienced dementia.

We found that there was a lack of activity for people living with dementia. The provider may want to consider more specialised training for staff particularly in relation to activities for people living with dementia.

We saw that people looked clean and tidy and well cared for and that the environment they lived in was homely clean and well maintained.

During our unannounced visit to The Cedars we spoke, in private, with three people who were visiting relatives, four people who were using the service and three members of the care team. This was in addition to discussions with the registered manager.

Everybody who we talked to was positive about the care provided and the attitude and competence of staff.

People living at the home were treated with respect and had their dignity and privacy maintained. People were involved in discussion and decisions about how their care was provided. People could choose whether to spend their time communally or in their rooms.

People's care was based on assessments of their needs which were regularly reviewed. The agreed way in which care was to be provided was recorded. There were internal systems within the home which worked well in keeping staff up-to-date with the changing needs of each individual.

There were systems in place to identify and report for investigation any concerns about abuse or exploitation. The system included staff members being thoroughly vetted before they started work at the home. Everybody who we spoke with told us they believed that people living at the home were safe.

Staff at the home enabled people to comment or complain about their care. All the people who we spoke with told us that they believed they could make a complaint and that their views would be listened to.