Archived: Cedar Lodge

Updated 17 October 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The Commission is aware of an incident which occurred in 2016 where a person died. This incident is subject to an investigation by the police and coroner. We did not examine the circumstances of this incident during this inspection. However, we did examine those at risk with nutritional needs.

Prior to the inspection, we wrote to the provider because they had failed to submit notifications without delay. We are taking action to deal with this matter outside of inspection and will provide an update when this matter is concluded.

We carried out an unannounced inspection on 8 May 2018 and 14 May 2018. Two adult social care inspectors, one specialist advisor and one expert by experience attended for inspection on 8 May 2018. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service Two adult social care inspectors attended for a second day of inspection on 14 May 2018. This inspection included observations of practice, discussions with people, relatives and staff and review of records.

Before our inspection we reviewed all the information we held about the service. We examined the notifications received by the CQC. Notifications are changes, events or incidents that the provider is legally obliged to send us within the required timescales. We also contacted Stockton Council Commissioning team, Health Watch, South Tees Clinical Commissioning Group (CCG) and Stockton NHS infection prevention and control team. We used the information shared with us as part of our inspection planning.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spoke with 11 people and three relatives. We spoke with the registered manager, rapid response manager, one nurse, one clinical lead, a senior carer and six care staff. We also spoke with a cook, a member of laundry staff, a domestic member of staff and a maintenance member of staff. We spoke with a community matron who visited the service during inspection.

We reviewed nine care records in detail. We reviewed four recruitment and induction records and ten supervision and appraisal records. We reviewed the training summary records for all staff. We also reviewed records relating to the day to day running of the service.

We carried out a short observational framework for inspection (SOFI). This method of observation is used to capture people’s experiences who are not able to voice them.

Updated 17 October 2018

Cedar lodge 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 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