The Cedars

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of 1 legal regulation in relation to good governance.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

People’s care plans contained important information about them. Including their nationality, religion or any individual communication needs they might have. The provider had values that confirmed what care and support people could expect of the service and staff. This included respecting people, providing care that was dignified, encouraging independence, providing compassionate, inclusive care that supported people, their health and wellbeing in partnership with them and others. Staff meetings provided an opportunity to discuss people’s support and any areas of improvement. All staff felt able to raise any concerns should they need to with the manager and provider of the service.

The service was managed by a registered manager who understood the context in which they delivered care, treatment, support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively.

The provider confirmed they visited the service weekly and liaised with the registered manager most days. All staff felt it was a nice place to work. Staff told us, “Really good manager” and “Nice, I like working here. The provider is really nice.” Positive feedback was provided by professionals who felt the service was positively managed. A professional told us, “(Registered managers name) has an open friendly approach.” They went on to say all staff were attentive and approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had regular supervision, staff meetings and the registered manager confirmed they liaised and updated staff as needed. Staff had their views sought through a staff survey. This was last undertaken in April 2025 with positive responses provided from staff. Staff told us they felt able to raise any concerns with the registered manager or provider if needed.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff felt supported and able to raise anything with the registered manager or provider if needed. The provider held opportunities within the service for staff to celebrate through cooking food that was part of their individual culture and custom.

The provider did not have good governance and quality assurance systems to identify where improvements were needed.

For example, we identified improvements needed to people’s care planning information, risk assessments for equipment and mobility needs, best interest decisions, and where medicines posed a flammable risk and needed further guidance such as a body map. Improvements were also needed to the décor and the environment and how personal protective equipment was being handled and disposed of. The providers existing governance arrangements had not identified these shortfalls.

The registered manager and provider was responsive to our inspection feedback and during the inspection they started to make improvements.

The provider’s statement of purpose had information such as the objectives for the services and who was managing the service. Although some additional information was needed about the provider and how the service supported people. The provider was displaying their CQC assessment rating within the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People had their views sought through quarterly resident’s meetings. These were an opportunity for the registered manager to get feedback from people and to gain their response to any improvements to the care and support provided. Relative’s surveys had been sent in June 2025 although the registered manager confirmed only 2 responses were returned. Feedback identified improvements needed to communication following people attending appointments. This feedback was also provided from relatives as part of this inspection. We shared this with the registered manager so they could review this and take any action needed. Relatives told us they felt able to raise any complaints should they have them with the registered manager. No complaints had been raised about the service. Positive feedback had been provided about the service and the registered manager. People and relatives were encouraged to give feedback through share your care experience and by filling in comments forms about the service which were available within the lobby area.

People were supported to attend community activities of their choice. This included accessing local shops and places of worship.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The registered manager collated information about incidents and accidents. Details of these were reviewed and any actions taken following the incidents were raised with staff through supervision and team meetings. The registered manager also collated any outcome and referrals made.