This inspection took place on 21 and 27 June 2017 and was unannounced.

Cedar House is registered to provide accommodation with nursing and personal care, diagnostic and screening procedures and treatment of disease, disorder or injury for up to 12 people. There were eight people living in the home at the time of this inspection and three people using the service for regular respite care.

The people living in the home all had multiple disabilities and needed full support with all aspects of daily living. The home is registered as a nursing home and there is one nurse on duty 24 hours a day plus support workers. The home is fully wheelchair accessible and has appropriate bathroom and hoist facilities for people with physical disabilities. Caretech Community Services (No.2) Ltd run this home and are referred to in this report as “the provider.”

The home has 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.

In October 2015 we rated this home inadequate and placed the home in Special Measures as the care was unsafe. Since then the provider and the management team have worked hard to improve the standard of care at the home. Prior to this inspection, we carried out an unannounced comprehensive inspection of this service on 10 June 2016 and served a warning notice on the provider requiring them to make improvements and become compliant with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safe Care and treatment. We carried out a focused inspection on 30 September and 5 October 2016 and found that the service had made the necessary improvements and met the requirements of the warning notice.

At this inspection we found that people’s representatives (relatives, advocates and professionals involved in their care) felt people received safe care and were happy with the quality of the service.

Staff supported people with their health conditions and ensured they received safe care and treatment. Medicines were managed safely. People’s mobility and medical equipment was safely maintained.

We made a recommendation about improving people’s emergency evacuation plans to ensure each person would be supported safely in the event of a fire. We also made a recommendation that the provider improves recruitment of new staff as they had not followed their own policy about references to ensure new staff were suitable to work with vulnerable people. Other recruitment checks had been carried out in accordance with legal requirements.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We found the service to be compliant with the legislation.

Staff gave people good support with their dietary needs and made the mealtime experience safe and enjoyable for people. Staff had formed good relationships with people knew their likes and dislikes and were able to understand their forms of communication which for some people meant observing their facial expressions and body language. There was a homely atmosphere in the home and staff engaged with people. With one exception, we could see that people felt comfortable and were smiling during our inspection.

We made a recommendation to improve the care for one person who was not receiving person centred care. The registered manager and provider acted immediately to make impr

This inspection took place on 30 September and 5 October 2016 and was unannounced on both days.

Cedar House is registered to provide accommodation with nursing and personal care, diagnostic and screening procedures and treatment of disease, disorder or injury for up to 12 people.

There were six people living in the home at the time of this inspection and one person using the service for regular respite care.

The people living in the home all had multiple disabilities and needed full support with all aspects of daily living. The home is registered as a nursing home and there is one nurse on duty 24 hours a day plus support workers. The home is fully wheelchair accessible and has appropriate bathroom and hoist facilities for people with physical disabilities. Caretech Community Services (No.2) Ltd run this home and are referred to in this report as “the provider.”

The manager of Cedar House was registered by the Care Quality Commission on 3 October 2016 and has been managing Cedar House for ten months. 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 carried out an unannounced comprehensive inspection of this service on 10 June 2016. Breaches of legal requirements were found. We served a warning notice on the provider requiring them to make improvements and become compliant with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safe Care and treatment.

We undertook this focused inspection to check that they had now met legal requirements. This report only covers our findings in relation to those requirements. 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”.

At the June inspection we found that the provider was not providing safe care and treatment. This was because they were not providing appropriate treatment for people with diabetes and they had not assessed the risks to people at night. Also, they had taken no action to monitor people who were at risk of having seizures at night. They also failed to ensure medicines were managed safely. Only one nurse had been assessed as competent to manage people’s medicines.

We checked all those concerns at this inspection and found the provider and registered manager had made all the necessary improvements to meet the requirements of the warning notice.

The care of a person with diabetes had improved and was being monitored by the registered manager and the lead nurse daily. Medicines were being given safely and managed appropriately.

Staff were monitoring people at night to ensure they were safe and well. All nurses had been assessed as competent to give and manage medicines.

During the inspection people were cared for well, kept safe from harm and staff supported them well with personal care, eating and drinking and taking part in their daily activities. People enjoyed music, massage, looking at books with staff, going to a daycentre, hydrotherapy and for a haircut during the inspection.

Staff told us they worked well as a team and were confident in the leadership of the home. People’s representatives (relatives, advocates and professionals involved in their care) told us they had seen improvements in the quality of care and had no concerns.

This inspection took place on 16 June 2016 and was unannounced.

At a previous inspection in October 2015 we judged that people were receiving inappropriate and unsafe care at Cedar House. We found breaches of six of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. The home was rated as Inadequate and the service was placed into Special Measures. 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.

We carried out another comprehensive inspection in January 2016 to see if improvements had been made to meet the fundamental standards. At that inspection we found breaches of five regulations. Improvements had been made and the home was rated as Requires improvement. The home remained in Special Measures as the leadership and governance of the home by the provider was still rated Inadequate.

At this current inspection we found further improvements. The home is still rated as Requires improvement but is no longer in Special Measures.

Cedar House is registered to provide accommodation with nursing and personal care, diagnostic and screening procedures, and treatment of disease, disorder or injury for up to 12 people.

There were six people living in the home at the time of this inspection. They all had multiple disabilities and needed full support with all aspects of daily living. The home is registered as a nursing home and there is one nurse on duty 24 hours a day plus support workers. The home is fully wheelchair accessible and has appropriate bathroom and hoist facilities for people with physical disabilities. Caretech Community Services (No.2) Ltd run this home and are referred to in this report as “the provider.”

The home has had no registered manager since March 2015. 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 current manager moved to Cedar House from another of the provider’s homes in December 2015. She has applied to be registered with the Care Quality Commission.

At this inspection we found there had been further improvements since January 2016. The provider had improved their monitoring of the home to find any concerns and act on them more quickly. There was good communication between the provider, the management team in the home and relatives of people living in the home.

There were improvements in the record keeping and monitoring of people’s needs. People’s fluid intake was now being recorded properly so that staff could ensure people were getting enough to drink. Staff supported people to change position regularly so that they did not get uncomfortable or develop pressure ulcers. People were taking part in more activities and were receiving regular physiotherapy from staff in the home. Staff had set up a sensory room and people were going out more. All these improvements had led to a better quality of life for people. Their relatives and professionals working with them said that the quality of care had improved.

We found breaches of one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was where the provider was not meeting the standard for safe care and treatment relating to medicines, diabetes and epilepsy. This regulation was breached at the previous two inspections. We are considering our regulatory response to ensure that these matters are addressed and will report further on this once this is complete.

We have also made tw

This inspection took place on 21 January 2016 and was unannounced.

At our last inspection in October 2015 we judged that people were at risk of receiving inappropriate and unsafe care. We found breaches of six of the Health and Social Care Act 2008 (Regulated Activities) 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. The home was rated as Inadequate and the service was placed into special measures. We carried out another comprehensive inspection in January 2016 to see if improvements had been made to meet the fundamental standards.

Cedar House is registered to provide accommodation with nursing and personal care, diagnostic and screening procedures and treatment of disease, disorder or injury for up to 12 people.

There were seven people living in the home at the time of this inspection. Six were present during this inspection and one was in hospital. Two people were using the home for respite care until October 2015 when the provider suspended the respite service due to the serious concerns at the last inspection about safety and quality of the service provided. The people living in the home all had multiple disabilities and needed full support with all aspects of daily living. The home is registered as a nursing home and there is one nurse on duty 24 hours a day plus support workers. The home is fully wheelchair accessible and has appropriate bathroom and hoist facilities for people with physical disabilities.

The home has had no registered manager since March 2015. 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 has been in special measures since October 2015. 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.

We found staffing levels had improved since the last inspection. Infection control, medicines management, provision of nursing care, reporting of safeguarding concerns, and recording care and treatment have all improved in the last three months. The provider had employed a temporary cook/cleaner and the home was cleaner and more hygienic than at the last inspection. There were more staff on duty during the day to meet people’s needs and less agency staff used. People’s health had been reviewed by professionals who had gi

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

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

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If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People are treated with respect and dignity by the staff. People told us they felt safe.

Safeguarding procedures were in place and staff understood how to safeguard the people they supported. We saw that care was delivered in safe, accessible surroundings that promoted people’s wellbeing. The home’s two lounges and kitchens were all clean and well maintained. We saw two bedrooms which were clean, bright, and tidy. Toilets and bathrooms were clean and the garden was maintained to a good standard.

Is the service effective?

People's health and care needs were assessed. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People were encouraged and supported to eat healthy, nutritious food. Relatives told us that they had been involved in the care planning process and that they were happy with the care that was provided.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person told us, "staff are very experienced.'' People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

Is the service responsive?

People’s needs had been assessed before they moved into the home. Records confirmed that people’s preferences, interests and aspirations had been recorded and that care and support had been provided in accordance with their wishes

Is the service well-led?

The Registered Manager had been in post for many years and had a good understanding of the needs of the client group. Staff told us that the manager was "hands on” and “she is very supportive.” A relative told us "she is a good manager, she keeps me up to date with what is happening."

Staff were clear about their roles and responsibilities, and 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.

We inspected the service on 6 September 2013 and found they were not meeting standards relating to the management of medication and records. As required (PRN) medication protocols for one person had not been correctly recorded and controlled drugs did not have the required two signatures. Records for people using the service were not accurate and up to date. This meant people were not always protected from the risk of unsafe or inappropriate care and treatment because of lack of proper information about them.

At this inspection we found that the provider had made some improvements. Controlled drugs audits had been introduced by the manager in October 2013 and most records relating to people who use the service were accurate and up to date.

At the time of our inspection there were eight people using the service. Most people were out at day centres or had gone shopping. We were not able to get verbal feedback from people using the service because people living at the home have complex needs, but we were able to observe and interact with them to know about their experience of living at the home.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. Staff were caring and respectful and we saw that people responded positively. One relative said of the care provided by staff as, “very good, I couldn’t have asked for a better place.”

There were appropriate arrangements in place to manage medicines safely. Staff with responsibility for administering medication had received appropriate training. However, medication audits were infrequent and we noted several gaps in recording.

People were supported to access other health and social care services they needed, including a speech and language therapist for people with dysphagia, difficulty swallowing and who had special dietary requirements.

Systems were in place to gather information about the quality of the service; however we were concerned that records were not always accurate or up to date.

People using the service were not able to give verbal feedback but we were able to observe and interact with them to know about their experience of living at the home. We saw some positive interactions between staff and observed staff caring for people in a respectful manner, by involving them in their care. People appeared comfortable in the presence of staff. We spoke with two relatives who spoke highly of the staff and service provided to their relative. “The care home is first class, I couldn’t fault it. Staff are very good,” commented one relative. “All very nice, very good at their job and very caring,” said another.

People were treated with dignity and respect. At the time of our visit we saw that staff were around to ensure that people were safe and received support that met their needs. People using the service were encouraged to make choices regarding their food, drinks and where they wanted to sit. We saw that people appeared appropriately dressed and well cared for. This ensured people using the service were treated with respect and their rights upheld.

Systems were in place to ensure that people were protected from abuse and that they received the care they needed. Systems were in place to monitor and to make improvements to the quality of care and support provided to people by the home. Staff felt supported by their manager and most had received regular supervision, staff appraisals had not taken place since 2010. The manager is currently addressing this.

None of the people we met were able to give verbal comments so we observed the body language and facial expressions of people using the service to gauge their satisfaction with the service provided. We also spent time in the care home observing interactions between members of staff and people living in the home. We saw that members of staff and people using the service were relaxed in each other’s company and there were smiles from people when looking at staff. Staff spoke kindly and respectfully to people and assistance with personal care tasks was offered in a discreet and polite manner. Members of staff demonstrated an awareness of people’s individual needs and provided assistance in a relaxed and supportive manner

We spoke with relatives that were visiting. A relative told us that “they got a good feeling about this one” when they were viewing Cedar House as a prospective care home placement for the person. Another relative said that it was “a very, very good home” and they liked the open house atmosphere, which meant that there were “lots of eyes” to monitor the service. They confirmed that the personal appearance of people using the service was maintained to a high standard and said that people were “always clean, always co-ordinated”. Relatives gave examples of activities that people took part in and these included day centre attendance, outings to West End shows, visiting Elstree aerodrome and shopping in Watford.

They told us that people using the service were safe and that “the staff were all caring human beings”. Relatives said that members of staff treat the people using the service as members of the family and that “they greet each one when they come on duty”. We were told that “staff co-operate and do things together”. One relative said that “sometimes it was busy” but thought that staffing levels were sufficient to meet the needs of the person. Members of staff were described as “approachable” and overall satisfaction with the service provided was good. Relatives that we spoke with couldn’t think of anything that had gone wrong where they would need to raise the mater as a complaint. The manager was described as “very good and efficient”.

We inspected this service over two days on 6th October 2015 and 13th October 2015. It was an unannounced inspection. We last inspected the home on 12th August 2014 and no concerns were identified.

Cedar House is registered to provide accommodation with nursing and personal care, diagnostic and screening procedures and treatment of disease, disorder or injury for up to 12 people. The people living at the service predominantly have learning disabilities and require nursing care. There were seven people living at the service at the time of inspection, with one bed being used regularly for respite care.

During this inspection we met the manager who had been in post since February 2015 and was in the process of submitting their application to become the registered manager. The conditions of registration for the service state that a registered manager is required. There was not a registered manager in place at the time of inspection and the last registered manager had de-registered in March 2015. A registered manager is a person who has registered with the Care Quality Commission (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.

Relatives told us the staff were caring but at times there were not enough staff. People’s privacy and dignity was not always maintained and there were not always enough staff to provide person centred safe care to people.

The staff we spoke with understood what abuse was and how to report it if they had any concerns, not all staff had been on safeguarding training.

Care documents contained information, such as people's personal preferences and how people communicated. These documents were not always up to date and review mechanisms were not in place to ensure that people's most recent needs were recorded.

Staff recruitment procedures were in place and the provider ensured that everyone had the necessary checks to ensure they were employing appropriate people.

However, we found several issues with the recording, storage, ordering and administration of medicines which put people at risk of harm because medicines were not safely managed.

There was a complaints procedure in place and available to people and visitors  but this was not being followed by the manager.

Appropriate arrangements were not in place to manage risks to people’s safety. Risks for people had not been identified or anticipated and people were at potential risk of receiving care and support that was unsafe and did not meet their needs.

We found overall that people were at risk of receiving inappropriate or unsafe care. We found breaches of six of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are taking enforcement action against the registered provider and will report further on this when it is completed.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.