Archived: Cedar Grange Residential and Nursing Home

We found the following examples of good practice.

The service had sufficient supplies of PPE and this was available throughout the service. Signage was in place regarding the requirement for wearing PPE and included guidance for the safe doffing and donning of PPE.

Staff came to work wearing their own clothes then changed into their uniforms in a designated room. This helped to reduce the risk of infection because staff did not enter areas of the home, where people lived, until appropriate infection control measures were in place.

The registered manager and staff had worked closely with external healthcare professionals to help ensure the service was following best practice regarding infection control.

The service was clean and hygienic. Additional cleaning schedules and audits were in place to ensure all infection control risks were minimised and people were kept safe. All high contact areas were cleaned in line with guidance provided by the local authority.

Procedures were in place regarding self-isolation for people and staff if they showed symptoms of Covid-19. At the time of the inspection the service was not admitting people to the service, however, the admission procedure had been updated and developed to reduce the risk of infection from Covid-19.

New procedures for visitors to the service had been developed. This included visitors making appointments and a designated room being made available for visitors to see people living in the service. Where visiting was permitted inside the service for compassionate reasons, for example, for people receiving end of life care, suitable infection control procedures were in place. Visitors were screened for Covid-19 prior to entering the service. Visitors were required to wear PPE at all times.

People were supported to speak with their friends and family using IT and the telephone, where possible.

Testing for Covid-19 had been implemented for all staff and people who used the service. Arrangements had been made to enable people and staff to access the vaccine.

Staff had completed online infection prevention and control and Covid-19 training. Other service specific training and information videos had also been developed to help ensure staff understood the different procedures in the home.

This unannounced comprehensive inspection took place on 22 May 2018. The last comprehensive inspection took place on the 14 and 17 March 2017 when the service was not meeting the legal requirements. The service was rated as Requires Improvement at that time. People's safety was not always protected. We identified issues in the recording and management of risks to some people. People who were vulnerable due to not being physically mobile, were not protected against the risk of other people entering their bedrooms and engaging in activities which were harmful. We took enforcement action against the service due to the concerns found at that inspection. We returned to carry out a focused inspection on 9 August 2017 to check on the action taken by the provider to meet the requirements of the regulations. At the focused inspection we found the service had made improvements and was no longer in breach of the regulations. However, the service rating of Requires Improvement was not changed at that inspection, as we required to see that changes were sustained over time. At this comprehensive inspection we found the service had sustained the changes made and had continued to make further improvements. The service is now rated as Good.

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 is required to have a registered manager and at the time of the inspection there was a registered manager 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 and associated Regulations about how the service is run.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes.

The premises were well maintained. The service was registered for dementia care. There was little pictorial signage at the service to support people who were living at the service with dementia, who may require additional support with recognising their surroundings. The décor of three of the units did not identify places easily for people. We have made a recommendation about this in the Effective section of the report.

The premises were regularly checked and maintained by the provider. Equipment and services used at Cedar Grange were regularly checked by competent people to ensure they were safe to use.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible.

The service had identified the minimum number of staff required to meet people’s needs and these were being met. The service had a number of staff vacancies at the time of this inspection and these posts were being filled by agency staff. The service was facing challenges in recruiting new staff. We were told this was due to businesses in the local area offering higher rates of pay.

There were systems in place for the management and administration of medicines. People received their medicine as prescribed. Regular medicines audits were being carried out these were effectively identifying if errors occurred, such as gaps in medicine administration records (MAR).

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

People had access to activities. Activity co-ordinators were in post providing some planned activities five days a week. Some people were supported to go out supported by staff, to attend appointments, have coffee or visit local attractions.

Technology was used to help improve the delivery of effective care. One person had movement sensors fitted in their room so that staff would know when they were moving around and may need support.

Risks in relation to people’s daily life were assessed and planned for to minimise the risk of harm. People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to all staff with regular updates provided. The manager had a record which provided them with an overview of staff training needs.

Staff were supported by a system of induction training, supervision and appraisals.

People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly. However, some information in care plans was misleading and could lead to some family members being asked to make decisions for which they did not hold the appropriate legal power to make. We have made a recommendation about this in the effective section of the report.

The manager was supported by the provider and a team of motivated and committed staff. The staff team felt valued and morale was good. Staff told us, “I am very happy here, it is a nice place to work” and “The manager is really good, she had made a lot of changes and is very approachable, her door is always open.”

There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by both the registered manager and members of the senior staff team.

There was a registered manager 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.

This unannounced focused inspection took place on 9 August 2017. The last comprehensive inspection took place on 14 and 17 March 2017. We identified breaches of the regulations at that inspection. The breaches related to the recording and management of risk, the management of medicines, lack of effective quality assurance processes and the poor compliance with the Mental Capacity Act (MCA). A warning notice was issued regarding the management of medicines and the recording and management of risk. Statutory requirements were issued for the other breaches of the regulations. The provider sent the Care Quality Commission an action plan detailing how the service would meet the requirements of the regulations. We carried out this focused inspection to check on the action taken by the service to meet the requirements of the warning notice. The action taken to address the requirements was also checked.

This report only covers our findings in relation to “Is the service Safe”; “Is the service effective” and “Is the service well led”. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cedar Grange Nursing Home on our website at www.cqc.org.uk.

At this inspection we found that action had been taken to address the concerns in the warning notice about the management and recording of risk and the safe management of medicines. We looked around the premises and found that the atmosphere had improved. People seemed calm and content. The doors to the downstairs units had been closed, meaning that people could no longer independently move between the two units. Some people had moved to different units, depending on their level of risk and need. There were new personal safety checks in place, so that people who were unable to independently use call bells were monitored every hour to help ensure they were safe. Locked water dispensers replaced the kettles in the kitchenettes, reducing the risk of people scalding themselves. We found one example where a risk assessment was not effectively implemented. The provider took immediate action to address this. We have made a recommendation about this in the report.

During this inspection we checked the services medicines systems. The management of medicines at Cedar Grange had improved and action had been taken to meet the requirements of the warning notice. At the last inspection, we found several medicines errors. These errors had not been reported as incidents and were not highlighted on the service’s medicines audit. This meant that learning from these errors might have been missed. At this inspection, we found that all errors were recorded as required.

During this inspection we reviewed the requirement notices in relation to compliance with the Mental Capacity Act. We found improvements had been made. Practices around covert medicines (medicines disguised in food or drink) had improved and there were clear best interest processes in place to ensure people’s rights were protected. The recording of consent had also improved, and we no longer found examples of people’s relatives consenting to their care without the correct legal authority to do so, such as a Lasting Power of Attorney (LPA).

The environment was spacious, bright and dementia friendly. For example, people’s bedroom doors and corridors were decorated individually to help people orientate themselves. One room had been decorated as a vintage tea room where people could go to enjoy afternoon tea. Another room was called the “Cedar Arms” and had a pub feel, with games machines and a pool table.

Staff received a suitable induction which including shadowing more experienced staff members Staff were supported with an on-going programme of supervision and an annual appraisal. Staff had received training in order to carry out their roles effectively and there was a system in place to remind them when it was due to be refreshed or renewed.

People had enough to eat and drink and there were a range of alternatives to choose from. People who required assistance with eating were supported by staff.

People had access to a range of health and social care professionals. People’s health care needs were appropriately monitored at the service, for example, there was a structured approach to the care of diabetes and tissue viability. Where risks to people’s health had been identified, these were well documented, monitored and linked to the person’s care plan to guide staff on what action they needed to take to support the person.

The provider undertook a range of audits to monitor the quality of the service and there was regular oversight and support from senior management. Feedback on the service was sought through a variety of forums, such as staff meetings, relatives’ meetings, comments cards and a regular cycle of quality assurance surveys. Feedback was used to raise standards within the service. Morale within the service was good and the individual characteristics of staff were recognised and celebrated by managers, for example through the staff awards ceremony. Staff had access to work related incentives such as a wellbeing scheme.

The service had a whistleblowing policy, which supported staff to question practice, defining how staff who raised concerns would be protected. The provider and registered manager promoted the ethos of honesty, learning from mistakes and admitted when things had gone wrong. This reflected the requirements of the duty of candour. The Duty of Candour is a legal obligation to act in an open and honest way in relation to care and treatment

At this inspection we found that the requirements of the warning notice and the requirement notices had been met, however the rating will remain unchanged in order for us to ensure that the changes made are sustained. This will be reviewed at the next comprehensive inspection of the service.

Cedar Grange provides care for up to 60 elderly people who require support due to old age, dementia, mental disorder, and physical disability. The home also provides nursing care. The building is split into four units or suites as they are known, each accommodating up to 15 people.

There was a registered manager 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.

People’s safety was not always protected. We identified issues in the recording and management of risks to some people. People who were vulnerable due to not being physically mobile, were not protected against the risk of other people entering their bedrooms and engaging in activities which were harmful. People did not always have call bells within reach and the stairgates intended to provide a barrier to people accessing bedrooms could be opened by some people living at the home.

People had risk assessments in their records, however these were not always reflective of the care being provided. There was an inconsistent approach to the recording of people’s resuscitation wishes, meaning that their treatment may not be provided in the way they wished, or might be delayed in the event of an emergency.

People’s medicines were not always managed safely. We found a range of errors on people’s medicines administration records (MAR). These had not been recorded on the computerised system as required. Although medicines audits were taking place, the frequency of these had been reduced from weekly to monthly, meaning that some incidents were not quickly identified. We found an excess of some medicines, expired medicines and medicines which had been opened without having the date of opening recorded.

Some people were prescribed medicine covertly; this means it was crushed in their drink or food. We saw that this had been agreed in consultation with the person’s doctor and this agreement was kept in their records. However, we saw little evidence of best interest processes to consider less restrictive alternatives to this practice. In addition, we saw that consent was not recorded appropriately in relation to people’s medicines, with relatives signing to give consent without the correct legal authority to do so.

There were systems in place to monitor the quality of the service at Cedar Grange, however these systems had not identified the issues we found during the inspection in relation to the management of medicines or the administration of covert medicines. In addition, the issues with the recording of consent and resuscitation wishes had not been identified. This meant that these systems were not always fully effective.

People and their relatives told us the service was safe. Staff had undergone training in safeguarding adults and knew what action to take should they witness a person being mistreated, including which external agencies they should alert. People were supported by staff who had been safely recruited. For example, they had undergone checks prior to commencing their employment to ensure they were suitable to care for people who were vulnerable. Although we observed suitable levels of care staff during the inspection, we were told that nursing staff felt under pressure at times and were often interrupted during their nursing duties, including medication rounds. We saw an example of one person missing their medication because the medication rounds had taken too long, meaning their doses were too close together.

People and relatives told us the service was caring. Comments from relatives included; “The staff show they care, they are so tender” and “They get the best out of my mum.” We observed kind and compassionate interactions between people and staff. People were treated with respect and their dignity and confidentiality were promoted by staff. People were encouraged to maintain relationships with people who mattered to them and there were no restrictions on visiting times.

The environment was spacious, bright and dementia friendly. For example, people’s bedroom doors and corridors were decorated individually to help people orientate themselves. One room had been decorated as a vintage tea room where people could go to enjoy afternoon tea. Another room was called the “Cedar Arms” and had a pub feel, with games machines and a pool table. People were seen spending time in these rooms and appearing comfortable and content.

There was a programme of activities for people to participate in, both inside the home and in the community. The service employed three activities coordinators who were constantly looking for new activities for people to enjoy. There were regular visitors and entertainment which people told us they enjoyed. People were encouraged to remain active outside of Cedar Grange and to form links with other generations. The home was using assistive technology to increase people’s independence and reduce risk.

Staff received a suitable induction which including shadowing more experienced staff members Staff were supported with an ongoing programme of supervision and an annual appraisal. Staff had received training in order to carry out their roles effectively and there was a system in place to remind them when it was due to be refreshed or renewed.

People had enough to eat and drink. People and their relatives told us the food was of sufficient quality and quantity and there were a range of alternatives to choose from. People who required assistance with eating were supported promptly by staff. The lunchtime experience was pleasant and sociable.

People had access to a range of health and social care professionals. People’s health care needs were appropriately monitored at the service, for example, there was a structured approach to the care of diabetes and tissue viability. Where risks to people’s health had been identified, these were well documented, monitored and linked to the person’s care plan to guide staff on what action they needed to take to support the person.

People and their relatives told us they knew how to make a complaint and felt that issues raised would be dealt with to their satisfaction. There was a process in place for receiving and investigating complaints which was underpinned by an up to date policy. Any lessons learned from complaints were shared with staff and used to drive improvement within the service.

The provider undertook a range of audits to monitor the quality of the service and there was regular oversight and support from senior management. Feedback on the service was sought through a variety of forums, such as staff meetings, relatives’ meetings, comments cards and a regular cycle of quality assurance surveys. Feedback was used to raise standards within the service. Morale within the service was good and the individual characteristics of staff were recognised and celebrated by managers, for example through the staff awards ceremony. Staff had access to work related incentives such as a wellbeing scheme.

The service had a whistleblowing policy, which supported staff to question practice, defining how staff who raised concerns would be protected. Staff confirmed they felt able to raise concerns and felt confident the management would act on their concerns appropriately. The provider and registered manager promoted the ethos of honesty, learning from mistakes and admitted when things had gone wrong. This reflected the requirements of the duty of candour. The Duty of Candour is a legal obligation to act in an open and honest way in relation to care and treatment.

We found breaches of regulation. You can see what action we told the provider to take at the back of the full version of the report.

We are considering our actions in line with CQC’s enforcement policy. 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.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

At the time of the inspection people told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Cedar Grange alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service.

Cedar Grange had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), and further staff training was planned. This helped to ensure that people's needs were met.

Is the service effective?

At the time of the inspection we found the service to be effective. People, or their representatives, were usually involved in writing or reviewing their plans of care. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people's needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw that there was good liaison and communication with other professionals and agencies to ensure people's care needs were met.

Is the service caring?

We spoke with people being supported by the service. We asked them for their opinions about the staff that supported them. At the time of the inspection feedback from people was positive, for example, 'I find the staff to be friendly, helpful and kind'.

Cedar Grange had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive?

At the time of the inspection we found the service to be responsive to changing care needs although staffing levels were an area of expressed concern for staff. Many people who lived at Cedar Grange had complex health needs and were either not able, or chose not to join in group activities. There was some, but inconsistent, evidence to show that people were routinely offered one-to-one time or group activities.

We found there was room for improvement with how the service sought people's views about the care provided.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

At the time of the inspection we found the service to be well-led. Cedar Grange had a registered manager. A new senior nurse had been appointed and started on the day of the inspection.

We saw minutes of meetings held with the staff. This showed the management had consulted with staff to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

The majority of people were happy with the care and support they received. Comments included ' I cannot find anything of fault,' the staff are 'very good to me' and 'I am very happy here'. Some people did say they thought there was at times not enough staff. The majority of people liked the food and said the staff were nice. We observed staff caring for people in a very professional manner. We had a meal with people who used the service and a choice was provided and the quality of the food was good.

Cedar Grange is a purpose built care home which has been open for approximately five years. Accommodation was designed, decorated, furnished and maintained to an excellent standard. When we inspected the home was clean and odour free.

A satisfactory system was in place regarding staff recruitment checks. There were some gaps regarding the provision of staff training. Quality assurance systems were generally satisfactory.

During the observations we saw staff helping two people to mobilise. We also saw staff conversing with people when they were laying up tables for lunch. We saw staff assisting people to eat their lunch. We saw people talking to each other at lunch.

We witnessed staff interaction with people which was generally positive.

We heard care workers ask people what they would like to do and gave them ideas if they could not make a choice.

People experienced care, treatment and support that met their needs and protected their rights.

People we spoke with said that they enjoyed the food they received. We were told the food was of a good standard, and we saw the food provided at lunch was hot, well presented and in sufficient quantities. We saw people were offered choices at meals.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We found staff received appropriate professional development and supervision.