Archived: Cedar Lodge

Cedar Lodge is a purpose built care home in a residential area of Stockton-On-Tees. The service provides care and support for up to 54 people who live with dementia and have nursing or residential care needs. Bedrooms and communal areas are provided over two floors. Each person has access to an en-suite bedroom and there are gardens to the rear of the service. 46 staff were employed. At the time of the inspection, there were 32 people using the service.

When we inspected in 2015, we rated the service ‘Requires Improvement’ overall. We found that staff training was not up to date and action needed to ensure all of the relevant checks for the building and equipment were carried out. We also found that a fire exit had been blocked which would have caused a delay in leaving the building during an emergency.

When we inspected in January 2017 we rated the service ‘Requires improvement.’ We found improvements had been made to staff training and relevant checks of the building and equipment had been carried out. However, we identified that there were insufficient catering staff deployed to meet people’s dietary needs. Palatable options were not available for people who required a soft or pureed diet and risk assessments for people at risk of malnutrition had not been completed correctly. Risks to people had not been managed consistently. We also found that the management of medicines needed improvement and there was a lack of meaningful activity for people. Care records were cumbersome, difficult to navigate and did not accurately reflect people’s needs. At the last inspection in January 2017, we asked the provider to take action to make improvements in all of these areas.

A registered manager had been in post since 7 August 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.

Since the last inspection in January 2017, eight incidents of abuse had been substantiated for neglect and organisational abuse. This meant there was evidence that abuse had taken place. Three of these alerts had been raised by the registered manager and five from health and social care professionals. Although staff had completed safeguarding training, they did not always recognise the risks to people. Care records and risk assessments were not always updated when incidents took place. There was no evidence that lessons had been learned.

Action had been taken to ensure more palatable meal options were available for people who required a soft or pureed diet. However, menu choices for the people requiring adapted diets did not provide a nutritionally balanced diet. Risk assessments for people at risk of malnutrition had still not been completed correctly.

Staff had not undertaken specific training in nutrition aimed at supporting people who were at risk of choking, dehydration or malnutrition with their dietary intake. Accurate records were not in place for people who displayed these risks and staff did not always follow the correct procedures to support people to ensure their nutritional and hydration intake was sufficient. From our observations and review of care records we determined that people with these risks were placed at an increased risk of harm.

Robust measures were not in place to appropriately assess people’s needs, the risks to them and then manage those risks. This included people at risk of falls, malnutrition and dehydration. People were also put at further risk of harm because staff did not follow health and safety procedures. This included not storing equipment away safely and rooms required to be locked for safely had been left open.

There were insufficient staff on duty at the service, which meant that people could not always go out into the garden or out into the community. People on the first floor were prevented from going downstairs by themselves because there was a risk of them leaving the building. No measures were in place to support people to go downstairs into the garden or out with staff. There were insufficient staff on duty on the first floor to attend to people’s personal care and this caused delays in people receiving assistance. When staff were providing assistance to people there were no visible staff.

Information in care plans was not always accurate. At times, the information contained within them was contradictory. Records had not always been fully completed with the information needed, signed or dated. There was a lack of meaningful activity in place for people.

People’s prescribed medicines were managed safely. However, there were delays in administering medicines when agency staff were on duty because there was a lack of support to these staff. ‘As and when required’ medicine records required further information to make sure staff unfamiliar to people had all of the information they needed to determine when it was appropriate to give these medicines. Systems to manage people’s topical creams needed to be improved. Records did not show if people received their topical creams as prescribed.

The service was clean and tidy. However, we found that staff did not always have access to the equipment they needed. We observed that staff did not always follow infection prevention and control procedures.

Health and safety certificates were up to date. However, there had been a delay in taking appropriate action when an electrical safety certificate had been rated as unsatisfactory. This issue had been addressed prior to inspection, however this delay put people and staff at increased risk of harm. Fire procedures had generally been carried out; however, records of some checks had not been kept up to date. Personal emergency evacuation plans were not accurate and staff did not know if one person with a sensory impairment would be able to hear the fire alarm. No actions had been taken to address this.

Confidential records stored in the manager’s office could be easily accessed from outside of the building as they were place next to an open window.

Staff had not received regular supervision and appraisal. Staff undertaking their induction had not always received regular reviews. All staff had undertaken mandatory training; however, the practices in place at the service showed that staff were not following the training they had received.

People were involved with health and social care professionals. Referrals had not always been carried out in a timely manner and care records had not always been updated to reflect the guidance or recommendations provided by them.

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. Staff worked in line with the Mental Capacity Act 2005. However, records for best interest decisions had not always been recorded.

Everyone using the service lived with dementia, yet the environment was not dementia friendly. Some areas of the service needed to be updated because plasterwork was damaged or walls were stained. Some equipment needed to be replaced or repaired. There was a lack of signage to help people to navigate their way around the service.

People told us they were happy with the care provided by staff. We observed positive interactions between people and staff when care was being provided. However, we found that staff did not always have time to spend with people. People told us that there were limited activities in place for them and we observed people sat in silence in communal areas for long periods of time.

People had access to some assistive technologies, such as wheelchairs and stand aids. However, they did not have access to records and information in large font or in picture format.

Complaints records were in place. People and relatives told us they knew how to raise a concern or complaint if they needed to. At the time of the inspection, no-one using the service was receiving end of life care.

Significant improvements had not been made since the last inspection. Many of the same concerns had been identified during this inspection. Quality assurance systems were in place; however, they had not been critical enough to ensure continued improvement at the service. Where actions had been identified, they had not always been addressed. Some areas for improvement had not been identified. Some changes had taken place, however further improvements were still needed.

We received mixed reviews from relatives and staff about the visibility of the management team. Staff worked together as a team and communicated with each other. Information was shared with people and staff during meetings with them.

Systems were not in place to make sure the Commission was made aware of incidents taking place at the service without delay.

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

We completed the inspection as concerns were raised by Stockton local authority, South Tees Clinical Commissioning Group and some relatives about the operation of the home. The inspection was also prompted. in part by a notification of an incident following which a person died. This is subject to an investigation and as a result of this we did not examine the circumstances of the incident. However the information shared with CQC about the incident indicated potential concerns about the management of the risk of choking. The inspection examined those risks.

We last inspected the service on 29 June and 5 July 2015 and found there were gaps in staff training and action needed to be taken to ensure all of the relevant checks were made of the building and equipment. We found that the home was breaching regulation 15 (Safety and suitability of the premises) and regulation 17 (Good Governance). We rated Cedar Lodge as ‘Requires improvement’ overall and in four domains.

In between our inspection visits, on 1 February 2017, the registered provider changed their name from Dolphin Property Company Limited to Mariposa Care Limited.

Cedar Lodge is a two storey building situated in the village of Norton, Stockton on Tees. The service is a modern purpose built building, which is registered to provide residential and nursing care for up to 54 people. The service provides nursing care for older people and nursing care for people living with a dementia. It is close to the village high street, local shops and other amenities that the community offers. When we commenced the inspection 39 people used the service.

The home has not had a registered manager since November 2016. 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. Mariposa Care Limited had recruited a person to be the registered manager.

We found that since November 2016 the service had been heavily reliant on the use of agency staff, particularly nurses for the top floor, and although action was being taken to recruit sufficient nurses this remained the case. The registered provider was ensuring there were sufficient numbers of nursing and care staff deployed at the home. They tried to ensure the same agency staff came to the home so there was some consistency but this was not always achievable.

The two floors operated very differently and like they were not a part of the same home. The downstairs unit for people living with dementia who required nursing care were fully staffed and this had led to the team addressing issues on the unit as they arose. This had not been the case on the upstairs nursing unit for older people.

The instability in the management team and high turnover of staff had led to the training objectives not being met and staff had not had supervision since the summer.

Every day we visited we found the home to be clean and infection measures such as access to antibacterial gels, aprons were in place. We heard from other visiting healthcare professionals that this was not always the case when they went to the service.

We found that overall the administration and management of medication on the downstairs unit was in line with people's prescriptions. However action needed to be taken to improve this on the upstairs unit. We found the nurses who had recently been recruited for the upstairs unit were in the process of critically reviewing medication practices on this unit and taking action to make improvements. .

People’s care records were cumbersome, extremely difficult to navigate and we often found it difficult to get a sense of the person’s needs. Staff needed to improve the accuracy of their recording when monitoring food intake, as they merely recorded menu choice and not the specific meal given such as adapted diets for people who required a soft or pureed diet.

We found that over 50% of the people who lived at the service needed either a soft or pureed diet. However the menu design did not assist the catering staff to meet the demand. The majority of meals were bread, pasta or pastry based, which cannot be readily turned into soft or pureed foods. In order to make the meals into the consistency needed for the adapted diet the catering staff were either combining all the ingredients into one or offering soup. This meant people either lived off soup or had unappetising bowls of a coloured material. We discussed this on the first day of the inspection and when we returned the regional manager told us that their head of catering had visited the staff to show them how to puree each part of the meal separately. However we saw the catering staff continued to combine it all together rather than puree each part of the meal.

Two kitchen staff worked each day and we found that this was insufficient numbers to give them time to ensure the adapted diets were provided.

Since October 2016 representatives from the senior management team and the internal quality compliance team had been working at the home. They had identified the issues we found and were actively putting measures in place to resolve these issues. They had also identified a number of other issues such as broken furniture, storage of equipment that was no longer needed, the need for permanent staff, staff not addressing peoples' personal care needs appropriately and taken action to deal with these matters.

We heard from visiting community matrons that since September 2016 they had observed marked improvement in staff practices and found that people who had fungal conditions, skin was cleaned more frequently. This had led to the conditions improving and being resolved in some cases.

The interactions between people and staff were jovial and supportive. Staff respected people’s privacy and dignity. People told us they felt the care staff did a good job. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were protected but records needed to be improved.

Safeguarding and whistleblowing procedures were in place. Staff reported concerns but needed to take ownership for reporting matters to the local safeguarding team. The registered provider’s recruitment processes minimised the risk of unsuitable staff being employed.

A complaints process was in place and any concerns were investigated by the regional manager or the quality compliance team.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our observations during the inspection, looking at care records and speaking with the manager, staff and people who lived at the service.

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

Is the service caring?

We found that pre admission assessments had been carried out and captured the needs of people who used the service. These details had been used to formulate an assessment of care needs for these people. Each set of records captured details of people's life history, people's preferences, likes, dislikes and routines.

Is the service responsive?

We found that there were no meaningful activities undertaken to engage or offer stimulation to people who used the service. Research shows that holistic care approaches to people who are living with a dementia can have a very positive impact on their day to day living.

We found that visiting professionals were involved in planning people's care and treatment. We saw instances that recommendations from these professionals were not always followed up or actioned by staff within the home. This meant that whilst planning of care had been assessed the interventions required had not been completed leaving people at risk of receiving inappropriate care and treatment.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home had submitted several DoLS applications to the local supervisory body in response to the impact a recent case law judgement had on people who lived at the home.

We found further evidence that where DoLS were considered by staff, they were done so without appropriate consideration given to the mental capacity of individuals. For example there was an assumption that people lacked capacity because they were living with a dementia.

We found that staffing levels at the time of our visit were acceptable to meet the needs of the people living at the service. We discussed with the management team the ongoing use of agency nursing staff. The team explained that whilst there was a higher than usual demand on the use of agency staff they were taking reasonable steps to address the issue and recruit permanent staff. People who used the service told us that they felt safe living at the home and that they felt the staff employed were appropriately skilled to deliver safe and appropriate care to them. Some people did voice concerns over the staffing levels on night shifts which we made the management team aware of during our inspection.

We saw the provider did not have effective systems in place to manage medicines. Records were incomplete or inaccurate and did not always reflect the medication administered to people. Incomplete record keeping meant we were not able to confirm that these medicines were being used as prescribed. Appropriate arrangements for ordering and obtaining people's prescribed medicines was failing, which increased the risk of harm to people and resulted in people not having their prescribed medication available to them.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. People we spoke with told us they felt safe at the home and were aware of who they could speak to if they wanted to raise any safeguarding concerns.

Is the service effective?

We saw that people were observed as being clean and well cared for and staff were attentive to people's needs.

Is the service well led?

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

We found that the home completed a range of audits on a monthly basis that led to the identification of areas of improvement throughout the service. We saw that at a provider level significant improvements had been made to ensure that internal monitoring of the service was effective and that the home was able to identify, learn from and improve areas of service provision.

What people told us:

We spoke with twelve people who used the service, eight relatives, two nursing staff and three care staff.

In discussions with people who used the service, they told us, 'The girls are very kind, they cannot do too much for you. I have never had a problem with anyone of them.'

'The staff are very good indeed, if you want anything doing, then you only have to ask. They keep my room nice and clean and my clothes are nicely washed and ironed."

'Well, if you grumble about these girls in here you would have to find something to grumble about. They are kind, always cheery and always do things willingly. What more could you ask for?'

'You can't fault these girls, even the cleaners. Everyone has a word for you and will help you with anything you need help with. No, no problems at all, I am very happy in here.'

'This is a lovely home to be in. If you need any help at all, all you have to do is ring and they come as quickly as they are able. I initially did not want to come into a home but I was unable to manage. This home has been a good choice for me.'

'We have plenty of girls during the day but at night, not every night by any means, if someone 'had an accident' and needed a lot of help then the two on duty can only see to that one person and you have to wait. They do come as soon as they can though.'

'Yes, lovely staff, anyone of them will help you but if they could have more staff at night it would be better. When you wake up and need the toilet and the two on duty are seeing to someone, then you have to wait. I got stomach ache once through waiting ' I know they could not help it but if one was free then she could see to someone like me. They are very good though, but an extra girl at night would relieve the pressure on the others.'

In discussions with relatives people told us, 'It would be helpful if there was an extra member of staff or two. Staff who could call in on mum for a few minutes to talk to her and hold her hand and reassure her. I know she is well cared for, but just little things, they mean a lot to mum.'

'There appears to be a good number of staff but if it was possible for them to have one or two more I think it would be helpful. Bells seem to be ringing most of the time and I see staff rushing to answer them.'

People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in a clean, hygienic environment.

The provider did not have an effective system to regularly assess and monitor the quality of service that people received.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We found that this care was delivered, in a clean, hygienic environment, by staff who were supported to deliver care and treatment safely and to an appropriate standard.

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

People we spoke with said, "The staff are very, very good and nothing is a bother", another person told us, "They really do everything that they can".

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

The provider did not have appropriate arrangements in place to protect people against the risks associated with the management of medicines.

People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found that there were enough qualified, skilled and experienced staff employed by the provider. We found that the provider was also taking reasonable steps to recruit and employ specifically qualified, skilled and experienced staff to meet the nursing needs of people who used the service.

One person told us "I love it here", and another person said that "I have had no concerns it seems fine."