About the service: About the service:

• Cedar House offers accommodation and personal or nursing care for up to 42 older people, some of whom are living with the experience of dementia. The accommodation is provided on the ground and first floor of a purpose-built building. There were 40 people using the service at the time of our inspection.

• Cedar House is part of HC-One Oval Limited, a large organisation which owns over 300 care homes across the United Kingdom.

People’s experience of using the service:

• We found that, although there were processes for auditing and monitoring the quality and safety of services people received, these had failed to identify the issues we had found in a timely manner so the provider could make the necessary improvements.

• Although some improvements had been made, some people stated there were not always enough permanent staff on duty, especially at weekends and during school holidays to provide continuity of care. The staff rota indicated all shifts were covered, although many by agency staff.

• People who required the use of hoists to mobilise did not have their own allocated slings. This meant there was a risk of cross contamination. There was a malodour in the downstairs unit which persisted throughout the day of our inspection.

• People who used the service did not always get the support they needed to eat, in line with their care plans. Therefore there was a risk some people did not receive enough food and drink to meet their nutritional needs.

• There were times when staff did not meet people’s needs in a person-centred way and were focused on the task they were required to complete. Some supported people without speaking with them or explaining what they were doing.

• The provider had processes for the recording and investigation of incidents and accidents. However, not all included actions taken to prevent reoccurrence and the lessons learned.

• People were supported by staff who were suitably trained, supervised and appraised

• There was evidence that people were offered a range of activities and an activity plan was displayed. The provider employed an activity officer who was planning to improve the provision of activities for people who used the service.

• Care plans were comprehensive and detailed. They contained all the necessary information about the person and how they wanted their care provided.

• Risk assessments were in place. These identified the risks that people faced and included guidelines for staff to follow to help ensure people were safe from harm.

• People’s healthcare needs were met because staff took appropriate action when concerns were identified.

• Medicines were safely managed. There were systems for ordering, administering and monitoring medicines. Staff received training in the administration of medicines and had their competencies checked.

• People’s end of life wishes were recorded in their care plans. These included their religious and cultural needs and where they wanted to receive care when they reached the end of their life.

• Recruitment checks were carried out before staff started working for the service and included checks to ensure staff had the relevant previous experience and qualifications.

• The environment was comfortable and homely and suited to the individual needs of people, such as people living with the experience of dementia.

• The provider acted in accordance with the Mental Capacity Act 2005 (MCA). Where people lacked the capacity to make particular decisions about their care, their mental capacity was assessed. Where necessary, people were being deprived of their liberty lawfully.

• Rating at last inspection: At the last inspection on 15 and 16 January 2018 the service was rated requires improvement in the key questions of ‘safe’, ‘caring’, ‘responsive’ and ‘well led’ and overall. Previously to this, we also rated the service requires improvement for two consecutive years. During this inspection we found the

We undertook an unannounced inspection of Cedar House on 15 and 16 January 2018. The inspection was prompted in part by the notification of an incident relating to the administration of medicines and concerns raised by relatives and visitors to the service.

Cedar House 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. Cedar House accommodates up to 42 people living with mental health support needs and dementia in a purpose-built building. There are two separate units, over two floors and each unit has two lounges and a dining room. At the time of the inspection there were 40 people using the service.

At out last inspection in September 2017 we rated the service as Requires Improvement and found a breach of Regulation 9 because the care provided did not always reflect the needs or preferences of people using the service. At this inspection, we found some improvements had been made in relation to the recording of personal care which met the wishes of the person and daily fluid intake.

At the time of the inspection there a registered manager in post and the provider had appointed a deputy manager since the last 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 using the service and staff felt that at times there were not enough staff to provide the level of support people required. There were times during the day when people were left unsupervised and without appropriate support as staff were supporting people in other parts of the unit.

People felt staff were kind and caring but, at times, were focused on the care tasks they needed to complete which meant they were not always able to identify if a person required support or reassurance.

The provider had a range of quality assurance processes to monitor the service and identify areas for improvement but some of these were not effective.

There was a range of activities provided and people were supported to be involved with both one to one and group activities.

The provider had processes in place to help keep people safe and protect them from abuse. People told us they felt safe when they received care.

A robust recruitment process was used to identify if new staff were suitable to provide care for the people using the service. Staff completed a range of training and regular supervision with annual appraisals to support them to provide care in an appropriate and safe way.

Incidents and accidents were recorded and reviewed to identify if there were any trends and actions required to prevent reoccurrence.

Medicines were managed and administered safely and people received their medicines as prescribed.

A detailed assessment of a person’s support needs was completed before they moved into Cedar House to ensure their care requirements could be met.

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 a choice of food every day and their dietary needs had been identified and were met.

People told us they were happy with the care they received, they were treated with dignity and respect and they were supported to maintain their independence.

Care plans included information for staff in relation to the person’s religious and cultural needs as well as their preferences for how they wanted their care provided.

Records were completed to identify incidents of behaviour which required additional support but th

This unannounced inspection took place on 4 and 5 September 2017. The last inspection of the service was on 14 and 20 April 2016 when we found breaches of the Regulations concerning standards of cleanliness in relation to equipment and communal bathrooms, staffing levels, care planning, activities and the effectiveness of audits and checks the provider carried out to monitor quality in the service. The provider sent us an action plan dated 24 August 2016 and told us they would take action to address the concerns we identified. The provider sent us updated versions of the action plan regularly and they told us they had taken action to address all of our concerns by the end of December 2016.

At the inspection in September 2017 we found the provider and registered manager had taken action and made improvements in most of the areas where we had concerns. However, further work was needed to make sure the service met all of the fundamental standards.

Cedar House is a purpose built home providing accommodation, nursing and personal care for up to 42 people with mental health and/or dementia care needs. The home is situated within a residential area of the London Borough of Hillingdon. At the time of our visit there were 42 people using the service.

The provider appointed a new manager in November 2016 and they registered with the Care Quality Commission (CQC) in February 2017. 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 one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider assessed people’s care and support needs and developed person-centred care plans to meet these. However, staff did not always record accurately the care and support people received and staff did not always follow care plans that had been agreed with people and that met their preferences. We also made a recommendation that the registered manager should review the deployment of staff to make sure people had the care, support and supervision they needed at all times.

The provider had systems in place to keep people safe and staff understood and followed these. There were usually enough staff to meet people’s needs but the provider needed to review the way they deployed staff to make sure they were available at all times. The provider carried out checks on new staff to make sure they were suitable to work with people using the service.

The provider carried out regular monitoring visits to the service and developed an action plan to address issues they identified. In addition, the registered manager and staff carried out regular checks on quality in the service and identified improvements they needed to make. However, the checks and audits the provider carried out did not always identify areas where they needed to make improvements.

The provider assessed people’s healthcare needs and gave staff guidance on how to meet these. People received the medicines they needed safely.

The provider carried out checks on health and safety in the home and took action when they identified areas they needed to address.

Staff had the training and support they needed to care for and support people using the service. The provider, manager, nurses and care staff had a good understanding of their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The provider did not deprive people of their liberty unlawfully.

People told us they enjoyed the food provided in the service.

People using the service and their relatives told us the staff who looked after them were kind and caring. We saw staff were kind, caring and gentle with the people they supported. We saw they allowed people time to mak

We undertook an unannounced inspection of Cedar House on the 14, 15 and 20 April 2016.

Cedar House is a purpose built home providing accommodation for up to 42 people with mental health and/or dementia care needs. The home is situated within a residential area of the London Borough of Hillingdon. At the time of our visit there were 38 people using the service.

We previously inspected Cedar House on 10 and 11 April 2014 and the provider had met all the regulations that were inspected.

At the time of the inspection there was 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.

People using the service were put at risk as standards of cleanliness were not maintained in relation to equipment and communal bathrooms

There were not always enough staff to meet people’s care needs appropriately and safely.

Care workers and nurses were sometimes busy which resulted in them not appropriately supporting people’s emotional and social needs as they were focused on tasks.

Care plans were not written in a way that identified each person’s wishes as to how they wanted their care provided. Daily records were focused on the tasks completed and not the person receiving the support.

The records relating to care of people using the service did not provide an accurate and complete picture of their support needs.

The provider had a range of audits in place but checks in relation to records of care and care plans did not identify issues noted during the inspection.

Activities were organised at the home but some of these were not meaningful for people and when the activities coordinator was unavailable there were limited activities organised. We have made a recommendation to the provider in relation to this.

People told us they felt safe when they received support and the provider had policies and procedures in place to deal with any concerns that were raised about the care provided.

The provider had processes in place for the recording and investigation of incidents and accidents. A range of risk assessments were in place in the care plan folders in relation to the care being provided.

The provider had an effective recruitment process in place. There was a policy and procedure in place for the administration of medicines.

The provider had policies, procedures and training in relation to the Mental Capacity Act 2005 and care workers were aware of the importance of supporting people to make choices.

Care workers and nurses had received training identified by the provider as mandatory to ensure they were providing appropriate and effective care for people using the service. Also care workers and nurses had regular supervision with their manager and received an annual appraisal.

We found breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to infection control, staffing levels, care plans, records and monitoring the quality of the service provided. You can see what action we told the provider to take at the back of the full version of this report.

We spoke with six people using the service, one visitor and seven staff. At the time of inspection twenty three people were accommodated at the home.

People said they were being cared for at the home. They told us they got up and went to bed when they wanted to and staff were available to help them. People confirmed they got a choice of meals and the food was “good”. One person said they enjoyed certain styles of music and staff understood this and provided it for them.

Comments we received from people using the service included “I like it here, I get on with people very well” and about the staff, “pretty good really.” A visitor expressed some concerns regarding the staffing levels at times and with their consent this was fed back to the manager, who said staffing levels were monitored in line with people’s needs.

Staff said they received training and updates on a regular basis and supervision was also now taking place more regularly, so they could discuss any issues and their professional development.

Systems were in place for quality assurance and work was ongoing to gain the opinions of people using the service and their representatives, with surveys being planned once more people were living at the home.

We used a number of different methods to help us understand the experiences of people using this service. We talked to staff and observed medication given to six people. We also looked at storage and record keeping of medication on two floors of the home.

We saw that nurses were very patient and reassuring and talked to people and explained the medicines that they were giving even when the person could not communicate. Two people were asked if they were in pain and we saw that pain relief was given appropriately and one person said that they did not need any medicines at that particular time.

People told us the staff helped them and treated them with respect. Relatives confirmed this. People said they could make choices about activities they wanted to participate in and about their meals. At mealtimes we saw that staff showed people the meals that were available and let them choose what they would like. Visitors confirmed that the meal options were always shown to their relative at mealtimes, so they could choose what they wanted to eat. Visitors said they had been involved in discussions about the care needs and wishes of their relatives.

People said the staff knew how to look after them and cared for them “well”. They told us the staff were “kind”. Visitors were happy with the care their relatives were receiving and felt this had improved with the new providers. They confirmed they had been kept up to date with the involvement of healthcare professionals.

People said they felt “safe” and could raise any concerns with staff. Relatives told us they were able to discuss any issues with the manager, which were listened to and where necessary, addressed.

People said staff were available to help them when they needed it. Visitors confirmed there were enough staff on duty to provide the help and support people needed.

Visitors told us they had been involved in relatives meetings and these had been constructive. They had been able to express their opinions at the meetings, which were listened to and acted upon. Visitors said they had noted improvements in several aspects of the service provision since the new providers had taken over, and felt the manager had worked hard to implement and maintain the improvements.

We spoke with four people using the service, one relative, one friend and three staff including nursing, care, the deputy manager and the registered manager. At the time of the inspection there were 36 people using the service.

The inspection was carried out by an inspector over two days. They helped answer our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe and well cared for.

The home was clean and tidy and people were able to personalise their rooms.

The medicines prescribed to people using the service were stored in a secure appropriate manner. The home used a computerised hand held system to record when medicines were taken by people using the service. We saw that the majority of records were correct but we did find that for one person there were more tablets for one medicine in stock than stated on the record system. We saw that the majority of creams and ointments that had a limited use once opened had the date of first use written on the packaging to ensure they were disposed of appropriately.

Systems were in place to make sure that staff reported any incidents and the manager reviewed and investigated any issues. Processes were in place for the manager and staff to learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The home had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Is the service effective?

People's health and care needs were assessed and they and/or their relatives were involved in the writing of the care plans which included any specialist dietary, mobility and equipment needs. The care plans, dependency assessments and risk assessments were regularly reviewed and were up to date to ensure people received appropriate care and support.

Is the service caring?

People were supported by kind, attentive staff who treated with respect and dignity. We saw they were supportive and encouraged people to be actively involved in their daily tasks and care. One person said, "The staff are really nice and never rush you". A visitor told us "The staff are superb with my friend and they give them time and encouragement".

Visitors confirmed they were able to see people in private and were able to visit throughout the day.

People's preferences, interests, and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People took part in a range of activities in and outside the service regularly. The home had its own adapted minibus, which helped to keep people involved with their local community. The activities were based upon people's interests and were responsive to individual needs.

The service had a complaints policy and procedure. The two complaints we looked at had been responded to and resolved. The relatives and visitors we spoke with were aware of how to raise any concerns but all said they would not need to make any complaints. One person said "I am really happy with the care here and would never have to make a complaint".

Is the service well-led?

The service had a quality assurance system in place. Records seen by us showed that any identified issues were addressed promptly. As a result the quality of the service was continuingly improving.

An annual survey was sent out to people using the service and their relatives and the results were used to identify any areas for improvement.

Regular audits of the care plans and risk assessments were carried out and any identified actions had a completion date. This helped to ensure that people received a good quality service at all times.