The inspection of Cedar Court Nursing Home (Dementia Unit) took place on 21 August 2018 and it was unannounced. Cedar Court Nursing Home (Dementia Unit) is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care is provided in one building with an accessible, secure garden. Some of the people are cared for in a male only environment on the first floor, called Bretby View. There are two communal areas on this floor and a further two communal areas on the ground floor. The home provides accommodation and nursing care for up to 50 people who are living with dementia. There were 41 people living at the service when we visited; including 15 men living in Bretby View.

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.

The service had been in special measures at their last inspection on 27 March 2018. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. After the last inspection, the provider sent us an action plan to confirm what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. Cedar Court Nursing Home (Dementia Unit) also had positive conditions on their registration since March 2017. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement so that we could monitor their progress towards their action plan. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

However, there were still improvements required to ensure that they provided people with a good service. The training and support provided to staff was not always sufficient to enable them to fulfil their role effectively. They did not always assist people to manage their behaviour when it could be harmful to themselves or others. They did not always take action to protect people or report all incidents. This meant that learning from when things went wrong was not always sufficient.

There were not always enough staff to meet people’s needs promptly. Staff were often rushed and task focussed leaving little time to comfort and reassure people. People had little interaction and no activities were provided to engage them. This impacted on people’s dignity which was not always respected. Their privacy was also not always upheld.

There were systems in place to drive quality improvement which included regular audits and feedback from people who use the service. However, some of the provider’s systems were not effective in ensuring that people were safe.

There were good relationships with other organisations and professionals; including working closely with commissioners to meet actions on improvement plans.

People were assisted to maintain good health and had regular access to healthcare professionals. Medicines were managed safely and people received them when they needed them. Mealtimes included a choice of meal and food and drink was monitored for people who were nutritionally at risk. Care plans were regularly reviewed to correspond with changing support needs and they were personalised and accessible.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way pos

This inspection took place on 18 January 2018 and was unannounced. The service had been in special measures since the inspection on 24 January 2017 and again from the inspection on 22 June 2017. At this inspection the overall rating for this service is Inadequate which means it will remain in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. 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

Cedar Court Nursing Home (Dementia Unit) has had positive conditions on their registration since March 2017. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement and at this inspection we saw that some further improvements had been made as the provider had reported. However, they had not completed all of the actions that were detailed and this impacted on the safety and wellbeing of people who lived at the home. Therefore, we will retain the positive conditions on the provider's registration until we are satisfied that significant improvements have been completed.

Following the last inspection, we met with the provider 18 July 2017 to confirm what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. At this inspection we found that some improvements had been made, however further improvements were required and we also had additional concerns in some areas.

Cedar Court Nursing Home (Dementia Unit) is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care is provided in one building with an accessible, secure garden. Some of the people are cared for in a male only environment on the first floor, called Bretby View. There are two communal areas on this floor and a further two communal areas on the ground floor. The home provides accommodation and nursing care for up to 50 people who are living with dementia. There were 36 people living at the service when we visited; including 14 men were living in Bretby View.

There had not been a registered manager in post for over one year. 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 ass

We inspected Cedar Court Nursing Home (Dementia Unit) on 22 June 2017 and it was an unannounced inspection. The home provides accommodation and nursing care for up to 50 people who are living with dementia. There were 36 people living at the service when we visited. There was separate all male accommodation upstairs in Bretby View and at the time of our inspection 15 men were living there.

The overall rating for this service is ‘Requires improvement’ and the service remains in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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.

After the last inspection on 24 January 2017 we put positive conditions on the provider’s registration with us. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement and at this inspection we saw that some improvements had been made as the provider had reported. However, they had not completed all of the actions that were detailed in their improvement plan and this impacted on the safety and wellbeing of people who lived at the home. Therefore, we will retain the positive conditions on the provider’s registration until we are satisfied that significant improvements have been completed.

The home did not have a registered manager in place; however, they did have a manager who was in the process of applying for their registration. 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 that risk was not managed sufficiently to ensure that people were kept safe. This was an issue at the two previous inspections. People were not always supported to move safely and the plans in place to protect people’s skin were not always followed to be effective. In the provider’s action plan they had addressed staff understanding of managing behaviour which could be challenging. They had also reviewed risk around peoples eating and drinking. However, the improvements did not address all r

We inspected Cedar Court Nursing Home (Dementia Unit) on 24 January 2017 and it was unannounced. It provides accommodation and nursing care for up to 50 people who are living with dementia. There were 42 people living at the service when we visited. There was separate all male accommodation upstairs in Bretby View and at the time of our inspection 17 men were living there. The overall rating for this service is Inadequate which means it will be placed into special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. 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.

The service had did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had recently employed a new manager. They had been in a temporary clinical lead role for three months and had been moved to the permanent managers post for less than one week when we undertook the inspection.

At our last inspection we saw that the systems in place to monitor and improve the quality of the care provided to people were not effective. We asked the provider to set an action plan to make improvements across the home so that people received support which protected them from harm. They returned the plan in the specified time but it was not detailed enough and we received an amended plan on request afterwards. At this inspection we saw that the provider had not made significant improvement in meeting the actions on the plan and that the systems in place to manage the service were not effective. The provider had also not notified us of all of the events that they should to meet their registration.

Risks to people's health and wellbeing were not managed to keep them safe from harm. When people behaved in a way that could cause them or others harm this risk was not always assessed. Clear guidance was not in place for staff to help people to manage this behaviour. When other risks were assessed the actions to reduce these were not always followed. People did not always receive their medicines as prescribed and the systems in place to manage the risks associated with them were not always followed.

When harm had occurred to people the circumstances around the incidents were not always thoroughly investigated or reported to the local

We inspected Cedar Court Nursing Home (Dementia Unit) on 7 January 2016 and it was an unannounced inspection. They were last inspected in December 2013 and were fully compliant against the standards we reviewed. The home provides accommodation for people who require nursing care and are living with dementia. There were 45 people living there at the time of our inspection. The accommodation was separated into two units with one unit providing accommodation for 18 male residents.

The home had a registered manager in place. 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.

Medicines and the risks associated with them were not effectively managed to keep people free from harm. When some people were given covert medicines a capacity assessment had not been completed and there was no record how this decision had been made in the person’s best interest. Some medicines were not securely stored and the stock of some medicine did not match the records. There were not always clear instructions to staff how to administer medicines and some recording lacked detail.

Other risks had not been effectively assessed, monitored or actioned to reduce them. We saw that there were hazards in the environment which could cause people harm. Some of the care that we observed was not in line with the recommended support agreed and put people at risk of harm.

The quality assurance processes in place were not always effective because they did not highlight the risks that we observed. We saw that audits were infrequent and that an action plan had not been put in place to check that improvements had been made. Also, when relatives of the people who used the service completed surveys and suggested where improvements could be considered this did not lead to action.

We saw that there was an inconsistent approach to assessment of a person’s capacity to consent to care. Some assessments were in place, but other important decisions were not supported by a capacity assessment or a best interest decision. The principles of the Deprivation of Liberty Safeguards had been applied within the home to protect people’s human rights.

We saw that there were enough staff to meet people’s needs safely. However, they were allocated to different communal areas during the day and this meant that it was difficult to respond to people on a personal level or spend time supporting people to pursue their interests or activities. Some of the environment did not have signs or decoration to support people living with dementia.

When staff did interact with people it was in a caring, considerate way. They were skilled and had received training and line management support to assist them to be effective in their job. We saw that people had their privacy and dignity respected. They were aware of how to protect people from abuse and knew how to report any concerns. Recruitment procedures had been followed to ensure that staff were safe to work with people.

People were supported to maintain a balanced diet and care was given to ensure that meals were prepared to meet people’s assessed need. People were monitored and referrals were made to relevant healthcare professionals when needed to ensure they maintained good health.

People knew who the registered manager was and stated that they were readily available and supportive. Staff told us that they were supported through regular supervision and appraisal. Systems were in place to receive feedback on people’s experiences.

We spoke with three people who used the service. Not everyone was able to share their views, so we observed the interactions between people and staff and general day to day practice and activities. Information about people's capacity to make decisions was recorded in their files People told us their privacy was respected and they made choices about their daily lives. Their comments included “They always knock and don’t just walk into your room” and “I go to bed and get up when I want."

We spoke with two relatives and asked them about their view of the care received. They told us “Staff are very friendly here and always have a word and a smile when I come to visit. I can’t fault what I have seen here, attentive staff ready to assist and spend time talking with X.” Both relatives told us they were kept informed about any changes.

The service provided people with a choice of suitable and nutritious food and drink. However, it was not always evident that staff were offering everyone a choice. People's dining experience depended on where they ate their meals, as we observed the lunch time to be disorganised in some area, and lacking in support for people who needed prompting to eat.

Systems were in place to ensure that people received their medication as prescribed.

Systems were in place to ensure that appropriate checks were undertaken before staff began work.

We visited Cedar Court Nursing Home (Dementia Unit) to follow up compliance actions made following our visit in July 2012. We spoke with one person who used the service and two relatives.

Both relatives told us they were very happy with the care and support provided. We saw staff were attentive to people’s needs. We watched staff sit and speak with people in the lounge areas, and engage them in activities. We saw staff assist people to maintain a well groomed appearance. People were assisted to wear tabards to protect their clothes when eating. Staff politely and discreetly asked people if they could wipe their hands and face once they had finished their meal or drink.

We saw registered nurses had sought advice and guidance from health care professionals when people had or were at risk of losing weight. Care plans had been updated to reflect the guidance provided. People were provided with calorie dense meals, snacks and food supplements as required. Systems were in place to ensure care records were up to date and accurate.

We saw that although improvements had been made regarding medication, people were not always receiving their medication as prescribed. Any shortfall in registered nurses’ practice had been identified and was being dealt with appropriately.

We saw that staff training was up to date, and sufficient numbers of registered nursing staff hours were being provided.

We spoke with eight people who used the service and three relatives. Not everyone we spoke with was able to share their views about the service. We also used the Short Observational Framework for Inspection (SOFI). The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. This includes looking at the support that is given to them by the staff.

We spoke with people on Bretby Unit. One person told us ‘It’s quite a nice place, very friendly, meals are very good not had a bad meal.” They also said “Not much to do, I read a magazine or do a word search.” Another person told us “It’s ok but not the best of places. I get bored as there is nothing to do; I’m not a TV person.” They also said “There is no opportunity to go out, I used to liked gardening but don’t get to go in the garden here.”

Relatives also commented about the lack of activities provided for people, and one relative commented about people on Bretby Unit not making use of the garden area for a walk.

Relatives commented on how well presented people looked, although two relatives commented about thier relative not wearing shoes or socks. We observed that people, especially on Bretby Unit were not wearing shoes or slippers.

The majority of people were unable to express their views regarding the service and support provided to them. One person we spoke with was able to confirm that the staff were supportive towards them. They told us “they’re lovely here, there’s always someone around”.

We spoke with two people’s visitors who confirmed that they were involved in the care planning for their relative. They told us that the home kept them informed of any developments in their relative’s treatment and health. Both families told us they had confidence in the home to look after their relative and felt they provided a good level of care.

One visitor told us about the concerns they had regarding the space available to her husband and the other men living in the men’s unit, as there was very limited communal space in this unit.

We visited Cedar Court Nursing Home (Dementia Unit) to follow up on enforcement action from our previous visit. We did not speak with people who used the service during this visit, although we spoke with the registered manager, a registered nurse and a care worker, and reviewed the quality assurance systems.

We saw that people and their relatives had been asked their views about the service through quality assurance questionnaires. We saw the information provided had been analysed and collated into a report. Areas for improvement were identified and proposed action included in the report.

We saw that a number of audits had been introduced. Medication records were checked to ensure that medication was written up correctly and given as prescribed. We saw an improvement over recent months, although a further check of medication in boxes was being introduced to make sure all medication was given as prescribed.

We saw care plans were audited on a regular basis. The audits identified areas within the care records that needed to be actioned. We saw a section for input from people who used the service and their relatives was included in the care plan audit.

We looked at the duty rota which showed the registered manager had protected supernumerary time, and she was not used as the second nurse on duty. We saw systems were in place to record when requests were made to agencies to cover shifts, but not when agencies could not cover shifts.