Archived: Cedar House

Cedar House is a residential care home providing accommodation and personal care for up to 17 people aged 65 and over, some of whom may have dementia. At the time of the inspection there were 16 people living at the home. The home is an adapted detached residential house. There is a garden to the rear of the property.

People’s experience of using this service and what we found

People told us they felt staff were kind and caring and felt safe living at Cedar House. However, we found significant concerns throughout the inspection. The home was dirty and parts of the home including the kitchen and furniture was in a state of disrepair. The home smelled strongly of urine and there were concerns around infection control in the kitchen area. People did not always have access to call bells.

There were few activities available to people and activities were not planned with an understanding of people living with dementia. Staff were not deployed across the home in a way that met people’s needs adequately. There was poor management oversight of the home and auditing processes were ineffective.

We observed some warm and caring interactions between staff and people. However, we also found instances where people were not treated with kindness and compassion. People who stayed in their bedrooms were often left alone for long periods of time. People were not always supported in a way that met their needs and ensured their physical and emotional well-being.

People did not always have choice around planning menus. Food was not always provided that was suitable for people. We have made a recommendation around this.

People’s personal risks were well assessed and provided staff with information on how to minimise known risks. People told us they were given their medicines on time. Staff understood safeguarding and how to keep people safe from abuse. Staff received regular training to support them in their role.

Care plans had been reviewed since the last inspection and were much more person centred. People were not involved in menu planning, although the cook told us that they asked people what they wanted each day. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 26 February 2019). We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following this inspection, the provider completed an action plan for breaches of regulations 12 and 18, supporting people with oral hygiene and staff deployment respectively, to show what they would do and by when they would improve. At this inspection enough improvement been made around regulation 12. However, regulation 18, in relation to staffing, had not been addressed and the provider was still in breach of regulations.

At the last inspection we also issued two warning notices for regulations 9 and 17, relating to care planning / provision of activities and management over sight and quality assurance respectively. The provider partially met the warning notice for regulation 9 and there had been a significant improvement in care planning, However, the provision of activities and engaging people was still poor and the provider remains in breach of regulation 9. The provider had failed to address the issues around regulation 17 and remains in breach.

At this inspection we also found a further breach around regulation 15, premises and equipment. People did not always have access to call bells, furniture, fixtures and fittings were in a state of disrepair. There was a new breach of regulation 12 around infection control. The home was found to be dirty and infection control was not addressed.

In summary, at this inspection we found beaches of regulations 9, 12, 15, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cedar House on our website at www.cqc.org.uk.

Enforcement

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.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At the last inspection in September 2017, which in part was prompted by a notification informing us of a person who was using the service to have alleged abuse, we again found the service to be in breach of Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The issues we identified included lack of appropriate detail of people’s risk management plans, lack of appropriate protocols relating to medicines which were to be administered on a ‘as and when required’ basis, people’s rights were not always met in line with the requirements of the Mental Capacity Act 2005 (MCA), care planning processes did not always ensure that people received care and support that met their needs, lack of sufficient person centred activities and inefficient management oversight processes meant that people’s needs were not always effectively met.

Following both inspections in 2017, the service submitted actions plans to us advising us of the improvements that they planned to implement to address these breaches. Whilst some improvements had been made over the last 12 months, we continued to find areas of concerns where the required improvements had not been made or sustained.

Cedar House is a privately-owned care home for older people in Enfield. 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 home is registered to accommodate 17 older people, most of them living with dementia. The home was fully occupied at the time of this inspection.

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.

Management oversight processes in place continued to be ineffective. Checks and audits were seen to be tick box exercises and did not identify any of the issues that we identified as part of this inspection.

Although care plans were detailed and person centred, and despite the service confirming they had been reviewed monthly, care plans were not always reflective of people’s current care needs.

Care plans detailed the support a person required in relation to their dementia, however, information was generic and had not been personalised to the person and how their dementia affected them.

People were not receiving the appropriate care and support in relation to their oral hygiene. Where people presented with certain habits that compromised infection control, the service did not ensure that steps were in place to support people with this whilst maintaining infection control.

People did not have access to meaningful or person-centred activities. Activity boards detailing scheduled activities were not current and activities that had been scheduled to take place in the garden or outside were inappropriate for the time of year.

People and their relatives commented that there were occasions were staff were not visible around the home especially in communal areas. We also observed this to be the case during the inspection.

People and their relatives told us they felt safe living at Cedar House. Staff demonstrated a sound awareness of the actions to take to report any concerns or signs of alleged abuse.

People received their medicines safely and as prescribed. Policies and procedures in place supported safe medicines management and administration.

Accidents and incidents were recorded with details of the action taken. However, systems were not in place to review and analyse these so that trends and patterns could be identified to support further learning and required improvements.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Staff understood the systems in place to protect people who could not make decisions and were aware of the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

The service had systems in place to ensure that only care staff assessed as safe to work with vulnerable adults were employed. Care staff were regularly supported through training, supervisions and annual appraisals to ensure they carried out their role effectively.

People were appropriately supported with their nutrition and hydration needs. However, we received mixed feedback about the quality of food people received.

People had access to a variety of healthcare professionals to support them with their health and care needs. Where the service identified specific needs or concerns referrals to the appropriate services had been made for people to receive the required support.

We observed people had established caring relationships with staff who were seen to respect their privacy and dignity.

People and their relatives knew who to speak with if they had a complaint or concern. However, some relatives did feedback that although they could raise concerns, these were not always addressed satisfactorily.

At this inspection we found continued breaches of Regulations 9, 12, 17 and 18 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.

During our previous inspection on 7 June 2017 we identified three breaches of the Health and Social Care (HSC) Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to staffing levels, infection control and good governance.

We rated the service during our inspection on 7 June 2017 overall requires improvement.

Cedar House sent us an action plan dated the 22 July 2017 advising us that improvements had been made to address these breaches. These included providing refresher training in infection control for care workers on 11 July 2017, and the implementation of a robust quality monitoring system to monitor and improve infection control practices. The service had appointed a manager, who recently left Cedar House, but a clearer management structure had been put into place. An interim manager had been appointed to oversee the service until a suitable manager had been appointed. The interim manager was supported by the operation manager. The provider told us in the action plan that the needs of people who used the service had been reviewed to ensure appropriate staffing levels were maintained.

Cedar House is a privately owned care home for older people in Enfield. The home is registered to accommodate 17 older people, most of them living with dementia. During the day of this comprehensive inspection Cedar House had six vacancies.

The home currently has no manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

People told us that they felt safe living at the home. Staff told us that they had received safeguarding training and showed an understanding of how to report safeguarding concerns.

Risks to people were not always managed effectively; risk management plans lacked detail and did not always provide appropriate guidance to staff to ensure safe care and treatment was provided.

Sufficient staff were deployed to ensure people’s needs were met and safe recruitment procedures were followed to ensure people were supported by staff that were appropriately vetted and checked.

While medicines overall were managed appropriately the lack of appropriate protocols and guidance in regards to administered medicines as required (PRN) could put people under unnecessary risk when receiving their medicines.

The provider ensured that appropriate infection control procedures were followed and that the home was clean and free of any offensive odours.

People spoke positively about the support they received. Staff told us that they felt supported in their roles.

We observed that people's consent was sought before they received support from staff and their decisions were respected. We found that processes were not always clear to ensure that all people’s rights would always be met in line with the requirements of the Mental Capacity Act (2005).

People had been involved in menu planning at the home to help meet their needs and preferences and we saw that people were given meal options.

We observed positive, caring interactions and relationships between people living at the home and

staff. People’s cultural and religious needs were catered for and care was provided discreetly and in a dignified manner.

People spoke positively about their care and the support they received. Care planning processes however had not always ensured that all people would always receive care and support that met all their needs. We saw that improvements had been made for people to access activities, however further work is required to ensure activities were person centred.

There was a complaints process in place and guidance about how to use this was on display at the home. Relatives and people who used the service told us that they would raise concerns with the management of Cedar House.

At the time of our inspection we found that some improvements had been made at the home, however audits and records were not always robust, and care planning and risk management processes had not always been effective to ensure that people's needs were always met.

The registered provider did not always uphold all of their responsibilities to the Care Quality Commission (CQC). 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.

We have found four breaches during this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Cedar House is a privately owned care home for older people in Enfield. The home is registered to accommodate 17 older people, most of whom are living with dementia.

There was not 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.

People told us that there were not enough care staff to meet all their needs. Staffing levels were not being calculated based on peoples’ level of dependency and current assessed needs.

Parts of the home were not cleaned to a satisfactory standard and infection control procedures were not always being followed appropriately.

There was not a satisfactory management structure at the home and it was often unclear to people who was in charge. Relatives and health and social care professionals had concerns about effective communication between themselves and management.

People using the service told us the quality of meals was not always of a satisfactory standard.

Staff were not always able to provide sufficient, meaningful activities for people who used the service.

Although most staff were up to date with their training requirements, all staff needed to undertake dementia awareness training as most people at the home were living with dementia.

There were systems in place to make sure staff were safely recruited and received regular supervision.

People told us they felt safe at the home and risks to people’s safety and been identified, acted on and, where possible, were being reviewed with the person.

Staff knew the signs to look out for that may indicate someone was being abused and they knew who to contact if they thought anyone was being abused.

There were systems in place to ensure medicines were handled and stored securely and administered to people safely and appropriately.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People had access to healthcare professionals such as district nurses, doctors, dentists and dieticians.

Staff understood that people’s diversity was important and something that needed to be upheld and valued.

People knew how to raise any concerns or complaints about their care and treatment at the home.

People were asked about the quality of the service and had made comments about this. These comments had been included in an overall improvement plan for the home which senior managers were working on.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to staffing levels, infection control and good governance. You can see what action we told the provider to take at the back of the full version of the report.

During our inspection on 9 June 2014, we found that the service was not meeting essential standards for requirements relating to workers, assessing and monitoring the quality of service provision, and record-keeping. The provider submitted an action plan detailing what they would do to meet the standards. During this visit, on 17 September 2014, we checked whether the provider had carried out the actions and whether the standards were now being met.

We found that, although no new staff had been employed at the service since our previous visit, the provider had a system in place to ensure that all required documentation was received from staff before they started work.

The registered manager had implemented a thorough, comprehensive system of weekly and monthly checks to ensure that the care people received was safe, effective and of high quality. They had also conducted residents' meetings to obtain feedback from people who used the service, and meetings with relatives to find out their views.

The registered manager had undertaken a thorough audit and checks of the personal care and support records of all people who used the service, and those we viewed were up-to-date and contained accurate information.

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that safer recruitment principles were not always followed, and staff were not always appropriately vetted before they started work.

The service was delivered in premises that were generally suitable, adequately maintained and met people's needs, however we noted there was not enough storage available for equipment.

People who used the service had appropriate risk assessments, and care plans described their needs well, however people's personal care and support records were not up-to-date or accurate. We observed that support was provided safely and following the guidelines detailed in people's individual care plans.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have been submitted, appropriate policies and procedures were in place.

Is the service effective?

We found that people received appropriate care and support that met their needs, and care we observed was provided with principles of dignity in mind. The support people received followed relevant research and guidance, particularly in the areas of skin integrity and supporting people who occasionally exhibited challenging behaviours.

People chose what they wished to eat from a range of options available, and food we observed being served looked and smelled appetising. People who used the service told us they enjoyed the food. One person said "The food is great, I enjoy dinnertime a lot".

People were supported to undertake a range of activities, although we noted that space within the service premises was not always appropriately used.

Is the service caring?

We observed that staff were attentive to people's needs, and took time to sit down and chat with people about topics of interest to them. Staff ate their meals in the lounge of the premises along with people who used the service, and chatted as they did so. Cards and letters received by the service noted the caring nature of the staff.

Staff we spoke with described people's different communication needs well, and were aware of the impact of communication on people's behaviour. Staff told us they enjoyed coming to work. One staff member said "It's a nice enough environment, but the people are lovely. I love my job, and I love that I get to help people live out their lives in comfort and peace".

Is the service responsive?

We found that people's personal care and support records were not always updated when their needs changed, nor did they always reflect people's day-to-day lives and experiences within the service.

Complaints were recorded and responded to appropriately, and the provider had a system in place to monitor these.

Is the service well-led?

The service had a Registered Manager in place who had clear responsibility for the day-to-day running of the service. However, the Registered Manager did not have appropriate systems in place to ensure that people's records were accurate and up-to-date, that staff were recruited safely, or that people's feedback was recorded and responded to outside of complaints.

Appropriate arrangements were in place in relation to the recording of all medicines. We looked at 13 medication administration records and found that all medicines had been signed for. There were no gaps in the medication administration records. The manager explained that since our last inspection she had introduced daily and weekly audits of medication administration. We looked at the last month's daily and weekly audits. These showed that there had been no errors in the recording of medication administration.

Medicines were not safely administered. Staff dispensed people's medication from small plastic cups carried on a tray. We saw that these contained printed labels with the names of people printed on them. Staff gave the pots to people, but did not have the medication administration records with them to check and sign that they had administered the medication to the right person. Appropriate arrangements were not always in place in relation to the recording of all medicines. When we looked at 17 medication administration records (MAR), we saw that medicines were not always recorded appropriately.

People's personal records including their care plans were accurate, and had been reviewed and updated at regular intervals. This meant that care records supported staff to provide safe and appropriate care to people who use the service.

Care plans were personalised and staff had used aids to ensure that people with communication issues were able to put their views across. Care plans told us that the people here received an effective service and had good links to all appropriate professionals.

We spoke to people who told us that they felt safe at this home. Staff were aware of signs of abuse and training records showed us that safeguarding training was mandatory.

Staff that we spoke with told us that they felt supported in all areas of their work including supervision and training. They however confirmed that they had not received any appraisals in the past year.

Safety records showed us that all equipment was regularly checked. Policies and procedures were appropriate and the service had made efforts to ensure that the home was continually looking to improve. This had not however been documented.