This inspection took place on 19 and 20 December 2018 and was unannounced. Cedar House was inspected twice in 2017. In June 2017, the service was rated overall requires improvement with breaches in Regulations 15, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to issues with staffing levels, infection control and good governance.

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

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

Cedar House is a privately-owned care home for older people in Enfield. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to accommodate 17 older people, most of them living with dementia. The home was fully occupied at the time of this inspection.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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

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

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

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

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

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

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

People received their medicines

This inspection took place on 7 June 2017 and was unannounced. At our last inspection in December 2015 the service was rated ‘Good’. At this inspection the service has been rated as ‘Requires Improvement’.

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

There was not a registered manager in post at the time of this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This inspection took place on 12 November 2015 and was unannounced. At our last inspection on 17 September 2014 the service was meeting all the standards we looked at.

Cedar House is a care home for older adults. The maximum number of people they can accommodate is 16. On the day of the inspection there were 14 people residing at the home.

A new provider had recently taken over the running of this service and prior to this, there had not been a registered manager in post for several months.

There was a newly 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.

Staff training had been inconsistent and not all staff had undertaken the refresher training they needed in order to keep up to date with current best practice.

People told us they felt safe and had no concerns about how they were being cared for at the home. They told us that the staff were kind and respectful and they were satisfied with the numbers of staff on duty so they did not have to wait too long for assistance.

The registered manager and staff at the home had identified and highlighted potential risks to people’s safety and had thought about and recorded how these risks could be reduced.

We saw that risk assessments, audits and checks regarding the safety and security of the premises were taking place on a regular basis and were being reviewed and updated where necessary.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and told us they would presume a person could make their own decisions about their care and treatment in the first instance. Staff told us it was not right to make choices for people when they could make choices for themselves.

People had good access to healthcare professionals such as doctors, dentists, chiropodists and opticians and any changes to people’s needs were responded to appropriately and quickly.

People told us staff listened to them and respected their choices and decisions.

People told us they were happy to raise any concerns they had with the staff and management of the home.

People told us they enjoyed the food and staff knew about any special diets people required either as a result of a clinical need or a cultural preference.

As this was a follow-up inspection to check whether actions we required from our previous visit had been carried out, we did not speak with people who use the service or their representatives at this time.

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

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

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

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

A single Inspector carried out this inspection. The focus of the inspection was to gather evidence to answer five questions: Is the service safe, effective, caring, responsive and well-led?

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

Is the service safe?

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

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

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

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

Is the service effective?

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

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

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

Is the service caring?

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

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

Is the service responsive?

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

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

Is the service well-led?

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

Our inspection of 19 August 2013 found there that medications were not administered safely and appropriate arrangements were not in place in relation to the recording of all medicines. The provider sent us an action plan which addressed our concerns. At this inspection we observed that medication was being administered safely. Staff checked the medication administration records before dispensing and giving medicines to people.

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

We observed that people were involved and consulted about decisions affecting their care. Staff knew how to communicate with people. A person said, "staff are helpful, they let me live as I want." People's needs were assessed and support was delivered to meet their individual needs. A typical comment was, "staff do their best to care for me.” People told us that when they asked staff to contact their general practitioner this was done quickly. One person told us, "if I need the doctor they arrange for him to visit promptly." People were able to access the medical care they needed.

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

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

On the day of our visit we observed staff treating people with respect and dignity and saw that people were given choices in areas such as food and clothing. We also saw that people’s views were sought with regard to what activities they would like to do.

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

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

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

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

People were being treated with respect. One person said, "Staff do listen to me and do things the way I want." People said that they received the care and support they needed. Staff were approachable and listened to what people had to say. People could discuss their concerns with the staff. A person said, “I can talk to staff if I was worried.” People told us that staff knew how to support them.