The Cedars

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as requires improvement. At this assessment the rating remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed However, the service had made improvements and was no longer in breach of legal regulations in relation to the need to consent.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. The registered manager listened to concerns about safety and raised incidents and safety concerns when required. All incidents were reviewed and actions taken by the manager who made referrals to professionals if required. The registered manager confirmed they continually identified and embedded good practice. They held discussions within staff meetings and supervisions if needed.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager confirmed they liaised with health and social care professionals as required and people were supported by staff to attend appointments if needed. This included GP, hospital appointments and other health appointments such as opticians and dental. Some feedback from relatives was mixed about the support provided to attend appointments. We raised this with the registered manager so they could review and take any actions needed. People’s care plans contained healthcare information along with the reason for their support.

The provider had systems to ensure concerns were shared appropriately and quickly. People’s care plans had important information such as if they had capacity or not. At our last inspection we found improvements were needed in the process and documentation for people who had mental capacity and best interest decisions in place. At this inspection we found most improvements had been made. Care plans confirmed if people had capacity or not and further information and guidance was available should staff need this.

However, we found improvements were needed to 1 person’s care plan as it confirmed they lacked capacity. No best interest decisions had been completed to confirm how to support them with their care and who had been consulted with those decisions. However, their care plan did contain important information to support staff in how to provide their care. We also found 2 people’s care plans needed up to date information on the Deprivation of Liberty Safeguard (DoLS) applications made by the service as details within their care plan was from previous applications and authorisations made. We raised this with the registered manager so they could review this feedback and take any action necessary.

Where people had capacity to make decisions about their care and support. This was detailed in their care plan along with any assistance or support they might need from staff. People were happy with the care and support provided. They told us, “Everybody is very kind.” Another person told us, “The staff are friendly and kind.” Staff had a good understanding of when to raise concerns and all felt able to raise these with the registered manager if needed.

Staff felt people got safe care. One member of staff told us, “Yes people get safe care.” The registered manager confirmed actions were taken when concerns were raised. Records confirmed these details along with any outcomes.

The provider did not always ensure improvements were being made to people’s care plans and risk assessments, so they contained important information about people and their individual risks.

For example, improvements were needed where 1 person was using the stair lift as they had no risk assessment in place confirming how to use this equipment. People who had pressure relieving equipment such as specialist beds had no risk assessment in place to support them. One person needed a risk assessment for the use of their mobility equipment. Another person raised their moving and handling support was unsafe. Following the inspection the registered manager confirmed they had liaised with the person and were providing care staff with further training.

We also found improvements were needed to 1 person’s care planning documentation, so it included information and guidance for staff to support the person with their diabetes care as this had recently changed.

People’s care plans had risk assessments in place where they were using walking equipment and wheelchairs and if they were at risk of falling.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. The provider was not always ensuring all aspects of the environment was fully maintained to a suitable standard as improvements were needed to the décor and to other aspects of the building including the main lift.

For example, the lift was not working and although the provider had made alternative arrangements with people using a stair lift. We found this might not be suitable for all people living in the service. A person’s care plan confirmed they used the lift with their walking equipment. Their care plan had not been updated to confirm the alternative arrangements now in place as the lift was out of order. The care plan had no risk assessment in how staff were to support them with using the stair lift. We raised this with the registered manager and provider during our inspection who took action to complete a risk assessment for this person.

The floor in the communal bathroom was stained and damaged and the floor in 1 person’s bedroom was also damaged. Other areas of the building needed to be re-painted and re-furbished. The bath had no assistance handles to support people to safely get in and out. Where water temperature checks were being completed these were on occasions above the recommended government safe temperatures. No actions had been taken prior to our inspection to address these shortfalls. Following raising this, the provider confirmed they had re-checked water temperatures that posed a risk and these were now within a safe range. They were also awaiting these to be reviewed by an external company.

The provider confirmed they had an ongoing refurbishment plan. However, not all areas of improvement were included within this.

Since our last inspection some improvements had been made by the provider to the building. This included the conservatory, a new roof to the back of the building and windows being replaced. Fire safety checks were completed weekly. The service had been visited by the fire service in December 2024 and October 2025. The provider confirmed where actions were still needed, they were making those improvements,

The provider had certificates in place that confirmed safety checks were undertaken on the water quality, electricity, gas and other equipment. People had an emergency evacuation plan should they need support in the event of an emergency.

The provider undertook safe recruitment procedures of staff. Staff felt supported although on occasions they said there were not always enough staff. Some staff needed to complete mandatory training to ensure they had the skills and knowledge to support people.

We observed staff supporting people with their routine care and support needs and also responding to when people needed assistance via their call bell. The registered manager confirmed they completed a staff dependency tool which reviewed what support people needed and there were no staff vacancies at the time of the inspection. Staff gave us mixed feedback on staffing levels within the service, commenting that on occasions people had to wait to have personal care provided and this could be as late as 11am or 11.30am. We raised this feedback with the manager and provider so they could review the staffing arrangements at certain times when people might need more assistance.

Staff felt supported by the registered manager and the provider. Staff completed mandatory training such as manual handling, safeguarding adults, mental capacity, equality and diversity and dementia care. The provider’s training matrix confirmed some staff needed training in, infection control, food awareness, diabetes training and additional practical training to support people with a learning disability and autism. We also found some improvements were needed where some staff were unable to demonstrate a good knowledge of how to support people with any equality and diversity needs. We raised this with the registered manager and provider so they could review what training staff required.

Staff had received training in how to support people with their skin integrity. This had been provided by external health care professionals.

The provider undertook safe recruitment procedures that ensured staff had satisfactory checks before working in the service to confirm they were safe to support vulnerable people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The provider did not always ensure suitable arrangements were in place to prevent the risk of infection.

The provider ensured staff had access to personal protective equipment (PPE). Although we were not always assured this was being handled correctly to prevent the possible spread of infections. For example, although staff had received training in how to use PPE. We found used personal protective equipment was not being disposed of as required. We raised this with the provider who took action to address this during our inspection.

People were supported to have vaccinations and care plans confirmed vaccinations people had received.

The provider did not always ensure suitable arrangements were in place to manage people’s medicines safely. Improvements were needed to guidance around application of topical creams and where topical creams posed a flammable risk.

For example, 2 people did not have a body map for their topical cream application, 5 people needed a risk assessment for emollient creams that posed a flammable risk. We raised this with the registered manager who took action during our inspection to address this shortfall. Temperature checks of medicines fridges were not always being documented. This meant medicines may not always be stored correctly. Where some medicines needed enhanced security arrangements these were not always being followed. Improvements were also needed to the documentation of some medicines stock.

Staff received training in the safe administration of medicines along with competency checks. Staff were observed to administer people’s medicines safely during the inspection. Medicines administration records (MAR) were accurately completed and included information about any allergies people might have. Medicines audits were not always identifying shortfalls found during this inspection. We raised this with the registered manager and provider so they could review the audits being completed.