We carried out an unannounced comprehensive inspection of this service in April 2017 and rated the service as Good. After that inspection we received concerns following a specific incident at the service which had a serious impact on a person using the service. This incident indicated potential concerns about the management of risk in the service. As a result we undertook a focussed inspection on 16 January 2018 to look into these concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cedar Tree Care Home Limited on our website at www.cqc.org.uk.

Cedar Tree Care Home Limited is a care home with nursing for older people, many of whom are living with dementia. People in care homes receive accommodation, nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, both of which were looked at during this inspection.

Cedar Tree Care Homes accommodates up to 40 older people in one purpose built building, fully accessible throughout. At the time of our inspection there were 39 people using the service.

The service had 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.

Staff understood how to recognise the signs and the many different types of abuse. They knew how to report any concerns they may have and were knowledgeable about how to contact external agencies with their concerns.

Potential risks people were exposed to were identified and regularly reviewed. Records included detailed information and guidance to support staff to carry out their role. Accidents and incidents were analysed, reviewed and actions taken to improve safety across the service.

There were robust recruitment processes in place. These helped to ensure staff were suitable to provide care and support. There were enough staff available to meet people's needs as assessed in their care plans.

People received their medicines safely and as prescribed.

Staff followed infection control procedures to control and reduce the risk of infection for people.

The management and leadership within the service had a clear structure and the registered manager was knowledgeable about people's needs and key issues and challenges within the service. Staff felt supported and enabled in their role. Diversity was recognised and supported within the service.

People and their relatives were supported to share their views about the service and these were respected and used to drive improvements and develop the service.

The registered manager and the provider had systems in place to monitor the quality of care and ensure the values, aims and objectives of the service were met. This included audits and checks of key aspects of the service, Outcomes were used to ensure people received good, safe care.

The inspection took place on the 25 and 26 April 2017, the first day was unannounced. The service was last inspected in April 2016, when it was rated as Requires Improvement.

The service is a residential service and is registered to care for up to 40 older people. On the day of inspection it was caring for 39 people.

There was a registered manager in post and they were present throughout the 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 were safe at Cedar Tree Care Home. Staff received training on how to keep people safe, and there were policies in place to support them if they had any concerns regarding a person’s safety. Equipment was checked and serviced as required and staff were trained on how to use it. Risks to people were identified and plans put in place to reduce the risk of harm. Medicines were managed safely and there was enough skilled and knowledgeable staff available to care for people.

Staff received the relevant training and support to meet the needs of people. Information was shared appropriately between staff and relevant health professionals to ensure people had consistent care. People had access to community healthcare services, as required. People enjoyed their food and were able to choose from a nutritious and varied menu. Special diets and preferences were catered for and recommendations from dieticians were followed.

People were cared for by staff who were kind, caring and compassionate. People were encouraged to share their views and their choices and preferences were respected. Staff cared for people with dignity and respect and promoted people’s independence and individuality.

Staff understood people’s needs and preferences, and took time to ‘get to know’ people, their lives, as well as who and what was important to them. There was a varied and inclusive activities programme which met people’s aspirations and was designed around people’s interests, special occasions and cultural needs. The registered manager proactively sought feedback and responded positively to comments and suggestions. Relatives praised the personalised care their loved ones received and described it as exceptional; they told us they had no complaints with the service.

The management team were praised by people, relatives and staff for their open and inclusive style of management, and for the support they offered them. The service was developed and managed with care and compassion, ‘from the top’ and responded to individual needs by developing a personalised service for people and their families. The quality assurance systems in place enabled effective monitoring of performance and led to good quality care for people.

The inspection took place on 15 April 2016 and was unannounced. The inspection team consisted of two inspectors, a specialist professional advisor who had experience in nursing, dementia care and end of life care and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. In this case the expert had experience of dementia care.

The service, located on Rowley Lane, Derby is registered for 40 older people, including those living with dementia. 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.

At our last inspection on 29 July 2013, we found examples of poor management of medicines which meant the provider had not always protected people from unsafe administration of medicines. We also found that staff were not always supported by the manager, as supervisions were not always conducted at the frequency described in the provider’s policy. These were in breach of Regulations 13 and 23 of the Health & Social Care Act (2008) Regulated Activities Regulations (2010) which following the legislative changes in April 2015, corresponds to regulation 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following that inspection the provider sent us an action plan, detailing how they would address these concerns. At this inspection we found that improvements had taken place to the management of medicines and the provider was now meeting the requirements of Regulation 12.

However, we still had concerns regarding supervisions at this inspection, and we have made a recommendation regarding the frequency and quality of supervisions in this report.

We found that risk assessments and care plans were not always updated following incidents. Therefore we could not be assured that people always received the most appropriate care to meet their needs. We also found that information about people was not always shared where there was a legal duty to do so, for instance safeguarding incidents. Therefore people were not always protected from the risk of harm or abuse. We have made a recommendation regarding the reporting of incidents and sharing information, in order to keep people safe.

We found a lack of understanding from some staff, regarding the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLS). Particularly how this impacted on their ability to care for people lawfully; especially where people had their movements restricted. For example, there were some people receiving restrictive care to keep them safe, which had not yet been legally authorised. We have made a recommendation regarding how the MCA and DoLS are applied when caring for people.

Staff received an induction where they were supported by the senior staff team to complete all the necessary training; and develop a thorough knowledge of the service and the people using it. This was supported by on-going training and supervision of staff. This meant staff were able to update their skills and knowledge to care for people effectively.

We observed positive caring relationships between staff and people using the service and their families. Staff clearly knew people’s individual needs, preferences and interests and provided care, support and activities in response to these. For example in response to individual interests and requests, there was a model railway in the lounge for people to use. There were also pet guinea pigs and birds, an outdoor seating area and a varied programme of events and activities that included the local community. This meant people had access to a variety of activities to suit thei

People told us that they were able to express their views and were involved in decisions about their care and treatment. They confirmed that daily routines were flexible and felt that their privacy and dignity was respected. People were also happy with the care they received at Cedar Tree Care Home.

Relatives were happy with the support provided. One relative said “I am very happy with the care and the staff are very good.” Another said “I wouldn’t move my relative from here as both I and the person who lives here are very happy with the care. I can not speak highly enough of the clinical lead nurse.”

Relatives told us they were involved in decisions about the care, treatment and support their family member received. One person told us they knew about their relative’s care plan and could ask to see the file at any time. They told us “The staff tell me straight away if there are any changes with mum.” Another relative told us they had been involved in the care planning process.

We saw people were offered a choice of meal, and the menu was displayed near the dining tables. People told us they enjoyed the meals provided. We saw people joining in with organised activities, or sitting quietly reading the newspaper or a book. One person told us they happy with activities provided.

People told us they felt safe and had not seen any care practice that gave them cause for concern. Relatives told us they had no concerns about staff practice and felt able to raise any concerns with staff.

One person told us that they had been able to look round the home before they moved in. Another person said, “They (the staff) know what I need. They help me to wash in the mornings and everything is alright here.” A visitor told us, “They always respect people here and they keep family informed. We have had meetings”. One person using the service told us that they felt they were involved and said, “I can tell staff if I need anything and they do something about it.” We saw that people had a choice of meals and appropriate help was given with eating when it was needed.

We observed staff speaking respectfully with individual people. There were some people whose first language was Punjabi and there were staff available who could communicate well with them.

Records showed that people had attention from professionals outside the home when needed. One person told us that hospital appointments were organised by staff at the home and that a member of the care staff helped them at appointments.

We found there was an effective care planning process, but there were no clear written plans about how people needed their medication. We did, though, see that nurses gave medication safely to people and people told us they always got their medication.

People told us the home was always clean and we saw that people had all the facilities and equipment they needed at Cedar Tree. One visitor said, “Oh it’s always clean here”. One person living there told us, “I like my room. They clean it every day.”

During the morning of our visit there seemed to be sufficient staff to meet people’s needs, but during the afternoon people were waiting for attention. There had been a shortage of staff due to sickness and no arrangements had been made for cover. The recruitment procedure for new staff was clear, but in practice this was not followed and staff were allowed to commence work before all checks on their fitness were completed. This meant that the providers could not be completely sure people in their care were protected. The staff we saw in the upper unit demonstrated their skills in working with people with needs relating to dementia. We saw people benefiting from staff speaking individually with them and occupying them. The staff there knew how to keep people safe. In the lower unit, staff showed they were skilled in moving people with a hoist when needed and they were working as rapidly as possible to meet people’s care needs. There was written evidence that staff were appropriately trained to meet people’s needs.

People told us that they felt respected whilst living at Cedar Tree. People told us they understood the care, treatment and support choices available to them and were involved in making decisions. One person told us “Oh yes, they treat me with respect. The staff are lovely. They talk to me about what I want and don’t do it without my say so!”

People told us they were very happy with the care that they received. One person told us “The care is brilliant. The staff seem to know when I want something or need assistance before I ask and they are there to help”.

The provider had clear systems in place to obtain feedback from all persons involved in the service as well as auditing their own service. This showed that the provider monitored the quality of the service it provided.

People were not protected against the risks associated with medicines as issues were identified during the inspection relating to people not always receiving medication at the times it was prescribed. There were, no 'as required' protocols in place to give clear guidance when certain medicines should be administered and there were gaps identified in the medication records.

People were cared for by staff who received appropriate training however the staff were not always suitably supervised and appraised.