OSJCT The Cedars

We found the following examples of good practice:

People were being supported to socially distance and isolate, where possible. Furniture in the home had been arranged to provide a distance between people. A visitor’s area was in the process of being built. Staff and professionals coming into the home were required to have their temperature taken, wash their hands, put on a facial covering, and change their clothing.

Risk assessments were in place to identify safe working practices.. Staff worked where possible on one floor of the home. When staff were required to work on different floors, they changed their personal protective equipment (PPE). Staff who were supporting people who had suspected or confirmed COVID-19 would not work in other areas of the home. Agency staff working at the home were required to only work at OSJCT The Cedars and not at any other location.

The home had enough PPE to support safe infection prevention and control. The PPE included fluid-repellent face coverings, aprons, gloves and visors. PPE stations were located throughout the home and staff had received training in how to use the PPE safely. Staff use of PPE and hand-washing was spot-checked by the registered manager.

There were cleaning schedules in place to ensure the home was clean and hygienic throughout. We saw appropriate cleaning products being used and the registered manager provided assurances that all staff were working to ensure thorough cleanliness.

People were tested monthly, or if they showed signs of potential COVID-19. All staff were tested weekly. There were risk assessments in place to support people and staff with backgrounds or specific health conditions which may make them more vulnerable to infection.

Further information is in the detailed findings below.

Rating at last inspection

The last rating for this service was Good (published 31 May 2019).

Why we inspected

We undertook this targeted inspection in response to a COVID-19 outbreak at the home. This was a targeted inspection around infection prevention and control practices. CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

At the previous inspection in November 2018, we rated the service as Requires Improvement. This was because although some improvements had been made, there were areas where further improvements were needed. At this inspection, we found many improvements had been made and areas where further improvements were needed, were identified by the management team. The service is now rated as Good overall.

Continued improvements were needed to ensure all care plans reflected people’s health needs and best interest decisions. However, there were more thorough care plan monitoring systems in place and there were some good examples of person-centred care planning.

We continued to receive mixed feedback about the food at the service. We saw that people had a choice of two different main meals at lunch time, and a range of lighter options in the evening. There were bowls of snack foods and a choice of drinks available in different areas of the home.

Work was taking place to create an open culture where everyone, including people, their relatives, and staff contributed to decisions about the service. This included identifying what everyone felt dignity in care meant.

People and their relatives had the opportunity to attend meetings to share their views. We saw staff asking people how they were and spending time with them. Relatives were welcomed to join people in activities or to visit at any time. People had access to different communal areas including quieter lounges, a large dining area, and spaces for activities.

There was a varied social programme of activities and events. Good community relationships had been formed, and there was support from volunteers.

Medicines continued to be managed safely. Records were up to date and monitored to ensure that people received their medicines and creams as prescribed.

The home was clean, tidy and free from bad odours throughout. Some areas had been redecorated and there were new carpets throughout the home. There were hand rails to help people move around the home safely.

People were supported by staff who received a range of training, including training in dignity and supporting people living with dementia. Staff received supervision conversations with their senior and attended staff team meetings.

People, their relatives and staff felt more supported by the home management team. We received positive feedback about how visible the home manager was.

Rating at last inspection: Requires Improvement (Report published 6 February 2019)

Why we inspected: Because the home had previously been repeatedly rated as Requires Improvement, we needed to ensure that improvements had been made.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

The Cedars provides accommodation and personal care for up to 49 older people. At the time of our inspection 44 people were living at the home, and three of those people were receiving care and treatment in hospital. Bedrooms were situated across two floors, with communal bathrooms throughout the service. People living on both floors shared the ground floor dining room and lounge areas.

The inspection took place on 27 and 28 November and was unannounced.

At the time of the inspection there were two registered managers. One of the registered managers was in the process of de-registering, due to a change in role; the other was on a period of extended leave. 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.

Overseeing the management of the service on an interim basis was a peripatetic manager. They were supported by the de-registering manager who had been appointed as the head of care. There was also a registered manager from the same provider based at the service as a supporting manager, one day per week. We met with the peripatetic manager, the head of care, the supporting manager, and the area operations manager during the inspection.

Most people and their relatives we spoke with were unsure who was leading the service.

Care plans for people with behaviours that staff found challenging to support were not detailed enough. The plans did not explain when staff should intervene in the person’s best interests. Staff did not follow the support plans and their interventions had not been reviewed to ascertain if they were the least restrictive options.

Where people displayed behaviours that staff found challenging, these were not recorded to identify if there were any patterns or trends in their behaviours. This meant that changes in behaviours were not being monitored.

The staffing numbers were decided using a dependency calculation tool, giving an expected number of staff and the lowest number that they could operate with. We saw that although the expected staffing number for night shifts was to have four members of staff on duty, frequently there were only three. We were told by different members of staff that one person required three people to support them with their personal care at one time. This left people at risk of not receiving support in a timely manner at night.

Some people and their relatives told us that they were not always able to have a bath or shower, or that their family member appeared to have gone for a long time without one. We checked the temperature records in the bathrooms, which should be completed each time a person has been supported to bathe or shower. Only 11 different people had received a bath or shower, according to the temperature records, throughout the four weeks prior to the inspection. Based on staff feedback and records observed, it was unclear if this was an accurate picture of the number of people supported, or if safety records were not always being completed.

At times, people’s dignity was not promoted. We saw people being supported with transfers using hoists. But, staff did not use the protective cover that supported people wearing skirts to maintain their dignity. Staff told us they knew why the cover was there, but they were not sure why some staff did not use it.

Activities were well attended and there was time allocated for one to one sessions, to support people at risk of social isolation. We saw festive activities were taking place and the activities staff had used their creativity to plan sessions that people enjoyed.

Staff told us that the communication amongst the staff team had greatly improved. The peripatetic and supporting managers explained that they had identified this was an issue previously at the service and one that they had worked to improve.

The carpets were in the process of being replaced. At times, work to the flooring was taking place outside of people’s bedrooms. We saw that the peripatetic manager spoke with people to explain what was happening and to minimise their discomfort.

Medicines management had improved. There were person-centred and detailed protocols for medicines required on an ‘as and when needed’ basis. Medicine stock checks took place, and the pharmacy had completed an audit. This was a recent improvement to the service, addressing shortfalls highlighted at the previous inspection.

Administration records for creams and lotions were not completed correctly or consistently. This had been identified by the management team and was in the process of being addressed as part of their ongoing action plan.

Staff told us they had received a lot of training. We saw from the training matrix that staff had been attending training and that where there were gaps in completed training, there were plans to address this.

At the previous inspection we had raised concerns about staff deployment. To partially address this, a care office had been implemented on the first floor, to stop staff needing to go to the ground floor to find information or records. There were also tools in place to allocate staff to working on set floors. The call bell response times showed that most call bells were responded to in a prompt manner.

Quality assurance processes had been implemented since September 2018 and were yet to become embedded into regular practice at the service. This included analysing falls, people’s weights, and reviewing care plans.

Relatives told us they were welcome to visit at any time. We saw people spending time with their relatives and relatives joining their family members at activity sessions.

We found one continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This is the fourth time the service has been rated as Requires Improvement. In line with our published guidance for repeated Requires Improvement, CQC will be considering what enforcement action to take. 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.

At the inspection on January 2016 we asked the provider to take action in response to our findings. A planned inspection took place in March 2017 to follow up on the concerns found at the previous visit. At this visit the service received a further rating of requires improvement and where we found breaches of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to risk assessments not in place or reviewed within designated timeframes. There was ineffective management of people’s behaviours that challenged and insufficient staff to respond to people’s needs. Records were not monitored correctly or accurately completed.

We took enforcement action against the provider and imposed a positive condition on the registration of this location. The service submitted a monthly improvement report to ensure that staffing, training and records are being monitored, audited and maintained in order to provide safe and effective care. However the action plan was not always consistent with the findings we found at this inspection.

At this inspection we found that the service had met one of the previous breaches identified and part of another breach. The service remained in breach of three Regulations, and were in further breach of other Regulations. This is the third consecutive time that this service has been rated as requires improvement and we are considering what further action will be taken in response. We met with this provider to discuss these concerns and seek assurance about the action they would take. The positive condition imposed on the registration for this location will remain in place until we re-inspect again shortly.

The registered manager was absent from the service and on a period of planned leave. 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 head of care had stepped up into the role of acting manager since February 2018 and was going through the process to become a jointly registered manager for this period of time. The acting manager and area operations manager were both present and available throughout our inspection.

Medicines were not always managed safely. People with prescribed time specific medicines did not always receive these on time. Stock levels of some medicines were not regularly checked. The service was in breach of this Regulation.

Risk assessments did not always contain enough detail to minimise the risk. Examples of unsafe practice were observed. The recording of people’s behaviour that at times challenged was not consistent or appropriate. The service remains in breach of this Regulation.

Although the levels of staffing were sufficient according to the provider’s dependency tool, the deployment of staff was not always managed efficiently. The service remains in breach of this Regulation.

We observed interactions where staff did not always act respectfully in regard to the people they supported or maintained their dignity. The service was in breach of this Regulation.

The service continued to have ineffective recording in care plans and monitoring records. The lack of appropriate recording meant that risks to people may not be identified in a timely manner.

.The service had remained in breach of this Regulation.

Quality assurance systems were in place. Despite identifying some of the same concerns we found during this inspection, action was not always taken in response to these. There was a lack of robust monitoring for documentation. Governance systems had not improved or were effectively maintained. Areas of concerns identified were not addressed to ensure people receive safe and caring treatment from staff. The service remains in breach of this Regulation.

People’s experience of care was assessed through feedback opportunities. We saw where comments had been made by people these were considered and actions discussed.

Some improvement had been made around mental capacity documentation, however consent to care had not always been sought in line with legislation.

Staff were not consistently supported to have regular supervisions with their line manager.

People were positive about the activities provided in the home; however we observed at times a lack of understanding from staff about how to provide activities for people with dementia.

People and their relatives were positive about the care they and their family member received. People told us they were involved in making daily decisions about their care such as when they preferred to get up, go to bed and preference on the gender of staff to support them.

Improvements had been made to the training and the recording of the induction staff received.

A registered manager was not in post when we inspected the service. 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. A manager from one of the provider’s other homes was managing the service and this manager has since become the registered manager for the service. The manager was present and approachable throughout our inspection.

At our previous inspection the home received a rating of requires improvement and were in breach of three Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection some improvements had been made but we found that the home had a repeated breach and further breaches of the regulation were identified. You can see what action we told the provider to take at the back of the full version of the report. We are taking further action in relation to this provider and 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.

Risk assessments had not always been put in place where there was an identified need. We saw some risk assessments were not being reviewed within the designated time frames to ensure they remained in line with people’s changing needs.

The home did not have effective measures in place to be consistent in their management of behaviours that challenged. Staff had not received training in this.

The recruitment of staff had remained inconsistent since the last inspection which had impacted on the care people received and the pressures staff felt.

Staff had a good understanding of how to identify safeguarding concerns and act on them to protect people. People we spoke with told us they felt safe living at The Cedars commenting “If I press the buzzer I don’t have to wait too long before someone will come and answer it. I do feel safe knowing there is help available if I need it.”

Staff had not always been given the opportunity to attend training and supervisions in order to develop and maintain their skills and receive support. The manager was in the process of addressing this.

The home had not always obtained the appropriate consent before taking decisions on behalf of people to ensure care was given in line with their preferences.

People’s healthcare needs were regularly monitored. There was evidence of regular consultations with health care professionals where needed and we saw staff seeking advice when needed.

People spoke positively about staff and the care they received. We saw that people were comfortable in the presence of staff and had developed caring relationships. One person told us “The staff are very kind to me, they look after me well.”

The service had remained in breach of the Regulation for ineffective recording in care plans and monitoring records. There was often inconsistent or conflicting information which made it hard to ascertain a person's most current needs.

The service had experienced a period of instability and this had impacted on people, their relatives and staff. A manager from one of the provider’s other homes was providing management support to the home and since we visited the service has become the registered manager. The manager was working hard to address areas of concern she had identified and an action plan was in place. Staff spoke positively about the support they were now receiving and told us the manager was approachable and available should they need to speak with her.

This inspection was unannounced. There was a registered manager in post when we inspected the service. 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 manager was accessible and approachable. Staff, people who used the service and relatives felt able to speak with the manager and provided feedback on the service.

A previous safeguarding had been raised in relation to managing pressure care at the home. An independent tissue specialist nurse attended the inspection and explored this area in depth. The findings showed preventative measures had been put in place and action taken to protect people from pressure sores. We found staff to be very knowledgeable on pressure care and people had access to the correct equipment to help minimise the risk of pressure damage.

Recording was not always completed correctly. The recording in people’s MAR’s (medicine administration records) for supplement drinks and the rotation of medicine patches was not completed. This meant people were at risk of not receiving their prescribed medicines in line with the GP recommendations. Fluid charts in place to monitor people’s liquid intake, had not been totalled correctly. This meant action that needed to be taken could be delayed as the monitoring system was not being used effectively to detect concerns. Care plan recording around people’s mobility and dependency needs showed inconsistencies where the old paperwork had been left in the folders. The most relevant information was placed at the back making it hard to identify a person’s current needs. This was a breach of the regulations.

People had a high number of falls. Whilst action around these falls had been taken we identified further precautions that needed addressing. The lighting in people’s bedrooms was inadequate, posing a potential risk for people with visual impairments. Equipment such as hoists and wheelchairs were repeatedly left in narrow corridors or seating areas causing a hazard for people unsteady on their feet. This was a breach of the regulations.

Where there was challenging behaviour displayed from people, the home would work to find a more suitable placement that could meet this person’s needs. Staff told us they were currently assisting one person who displayed aggressive behaviour. Three staff members would often attend this person and staff had not received appropriate training around safe method of restraint. This meant that this person and staff were potentially at risk from unsafe practices and a lack of knowledge. This was a breach of the regulation.

These breaches can be read about in more detail in the full version of the report and the action we have told the provider to take.

The service had a strong commitment to supporting people and their relatives at the end of their life. The management team were determined that people should remain in the home being cared for by the staff they knew unless the home could not provide the level of care someone might need at end of life.

People told us they felt safe living at The Cedars and they were well cared for. The provider had systems in place to manage risk and protect people from abuse. Staff had a good understanding of safeguarding and whistle-blowing procedures. They also knew how to report concerns and had confidence in the manager that these would be fully investigated to ensure people were protected.

The home was piloting the new care certificate induction. New starters told us their induction prepared them well for their role and they were able to shadow experienced team members and get to know the people they would support. The manager spoke about how the induction should increase staff retention as they can offer more individual support in the area a new employee needs it.

People and relatives were very complimentary about the caring nature of staff. Staff were knowledgeable about people’s needs and people’s privacy and dignity was always respected. Staff explained the importance of supporting people to make choices about their daily lives. People told us they were involved in decisions about their care and systems were in place to monitor and review people’s changing needs.

The manager had implemented many changes within the home and people and their relatives spoke highly of the positive direction the home was taking under the managers lead. Staff felt confident and comfortable in approaching the manager and had faith concerns raised would be actioned.

We found that people were involved in menu planning and enjoyed a varied diet that met their individual needs.

People told us they were happy living in the home and were mostly complimentary of the services provided and of the staff team. Comments included, 'when I first came here I was sad, but now I am ok as it is pretty good'. 'Staff are all very nice', 'some staff will only do what is needed'. We have told the provider that some people were concerned that there was not always enough staff around during busier times of the day, such as meal times.

The provider had ensured staff received appropriate professional development and support to safeguard and deliver care to the people who lived in the home.

We found that people and their relatives had opportunities to contribute their views about the quality of the service. The provider had systems for monitoring services provided.

We have not revisited the Cedars care home as part of this review because they were able to demonstrate that they were meeting the standards without the need for a visit.