The inspection took place on 31 August and 2 September 2016 and was an unannounced inspection. The inspection prior to this on 10 July 2013 found the standards inspected were met.

The Cedar Gardens Care Limited is a nursing home registered to provide accommodation for a maximum of 45 people requiring nursing or personal care. The home provides a service to adults of all ages who may have a range of disabilities including dementia, learning disability and autistic spectrum disorder, mental health, eating disorder and misuse drugs and alcohol.

There was a registered manager at the service. 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 received good overall feedback about the service. There was particular praise for how people’s health needs were addressed. The staff supported people well with healthcare matters and people had access to the nursing staff and were supported to access appropriate medical care. The service had an excellent record of pressure ulcer care utilizing the provider’s tissue viability nurse support. In addition the staff were friendly and caring towards people, and welcoming to their visitors. Nurses were knowledgeable about people’s medicines and medicines administration and storage was undertaken in an appropriate manner.

We found that the service had systems in place to recognise and report safeguarding adult concerns. There was a robust recruitment procedure and staffing was assessed on an ongoing basis to ensure the changing needs of people using the service were met. People and the environment were risk assessed and reviewed to reflect any changes in circumstances.

The service was clean and well maintained. Staff had received infection control training and understood good practice in preventing cross infection.

The service was working to the Mental Capacity Act 2005 and the management team understood their responsibilities under the Deprivation of Liberty Safeguards to ensure that people’s legal rights were being upheld.

Staff received regular supervision and training and were well supported by a proactive and accessible management team.

People were supported to eat a healthy diet and remain well hydrated and although some people liked the meals provided others were not so complimentary. We brought this to the attention of the manager who was in the process of compiling new menus to trial. She undertook to continue the work to ensure all people were happy with the selection of meals.

People had person centred plans that reflected their likes and dislikes and told staff how they wished to be supported. Care plans told staff about people’s histories and named activities that people enjoyed. There was care taken to ensure activities were varied and involved people with different cognitive functioning.

The service was well- led by a strong management team who were visible and accessible to both staff and people using the service. The registered manager and deputy manager were both passionate about their role in ensuring good care and were well supported by the nursing staff and the provider management team. People and visitors told us they could raise concerns and any issue raised was addressed immediately by the registered manager.

The views of people, their visitors and staff were sought by the management team who responded to the outcomes of surveys and initiated changes suggested.

During our last inspection in April 2013 we found that the recording of supervision meetings did not demonstrate that supervisions were held as frequently as stated in the provider's policy. During our July 2013 inspection we found that the provider had focused on increasing the number of supervisions and improving how they were recorded and planned. Records of supervision and appraisal meetings included discussion of staff's strengths and development needs and we found that teamwork and person-centred care had been emphasised. This meant that people were supported by appropriately trained and supervised staff.

A new system to record training required and undertaken was in place and linked with the development needs identified in supervision and appraisal meetings. This included professional nursing courses. The home had been selected to participate in a pilot training programme offered by the London Borough of Barnet which would enable them to further develop staff and offer training to other providers. This meant that people were cared for in an environment which was striving for clinical excellence.

People were provided with a choice of suitable and nutritious food and drink and one person told us “the food is good here,” The home had systems in place to ensure people received adequate nutrition and hydration.

People who use the service were protected from the risk of abuse. Staff were guided by training and documents available and people told us they felt safe in the home.

The provider had made several improvements to the premises in accordance with our last inspection.

Staff providing care to people were subject to a number of checks before starting work and received regular training. Supervision meetings took place but the provider accepted the recording of these did not demonstrate that supervisions were held as frequently as stated in the provider's policy.

A person we spoke with who lived in the home said “I’m perfectly happy here”. People were spoken to respectfully. A varied person-centred activities programme was enjoyed by people living at the home. People said they were involved and respected.

Care plans were individualized, comprehensive and reviewed regularly. We saw relatives’ signatures to confirm their involvement. People were receiving the care and treatment they needed.

There were ongoing problems with a number of issues relating to the premises. The home’s own audit procedures identified them but they had not been resolved promptly. The lift had broken down more than once in the year and there had been no communal bathroom in working order on the first floor since October 2012. The home was not meeting its own policy which stated its premises must be fit for purpose and safe.

There were enough qualified, skilled and experienced staff to meet people’s needs. One person said “staff come when I ring the bell.”

The provider had an effective system to regularly assess and monitor the quality of service received. We were shown a large number of audits carried out in the home on an ongoing basis. Aside from the delays outlined regarding the premises, we could see that action had been as a result of these audits.

People who use the service and their relatives told us that staff involved them in decisions about their care and treatment. They said that they were involved in the assessment and care plan reviews. We were told that the manager was available and they could talk to her and staff.

We observed that staff interacted with people while supporting them. We observed that staff treated people with respect.

We saw that people were able to make decisions about their care and the service they received. People told us that they could make decisions such as when to go to bed or get up. The relatives we spoke with told us that the home always sought their consent when decisions were made. A relative told us how they recently decided against a planned service which they thought was not beneficial for a person who uses the service.

Relatives told us that the home provided care that met people's needs. They said the home invited them to attend review meetings. They said they were satisfied with the care and thought people were well looked after. We observed people to be relaxed and presentable. A person told us that they were happy and their needs were met. They said: "I go to religious meetings". We observed people taking part in activities in the lounge. People told us that they enjoyed their activities.

People told us that the home provided good food. For example, a person said: "The food is nice; the cook is very good". From observations people appeared to have enjoyed their meals. We saw that people had an opportunity to choose the kind of food they wanted. We saw that staff supported people with their meals in a respectful and dignified manner. People who were able to do so were encouraged to eat their meals independently.

We observed that people who use the service could speak with staff if they had concerns. People we talked to confirmed that they knew how and who to complain to if they were not happy about anything. A person said: “I know I can talk to staff or the manager”. We observed that staff were attentive to people’s needs and asked people if they had concerns. We saw the acting manager was accessible to people and relatives.

Relatives talked about the staff positively. Comments they made included: “The staff care about people; they are kind; I trust them”. However, people were not confident that there were sufficient numbers of staff. People said: "There are not enough staff here”.