Cedar Lodge

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 good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to people’s safe care and treatment and premises and equipment.

This service scored 44 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Systems were in place to report accidents and incidents, and staff told us they felt confident in raising concerns. However, we found that lessons from previous incidents had not been fully translated into improvements in care delivery or actions taken to prevent reoccurrence. For example, following 1 person going missing from the garden within Cedar Lodge unit in November 2025, people were stopped from using the garden. At the time of the assessment the garden was still inaccessible. Staff also told us 1 person living on the top floor of the home moves fire extinguishers, places them on the top step of the stairs, and takes the labels off meaning staff were unaware of where they should be placed. We were told this had been reported to management, however no risk assessment was in place and although this persons’ care plan stated they should be checked hourly, there was no evidence that this was always being completed. This meant opportunities to learn and improve practice were not always acted upon effectively. We discussed the concerns with the management team who rectified them during the assessment.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

Although the managers and staff described how they worked with external professionals, including GPs and district nurses, we received mixed feedback from professionals regarding this. Two professionals told us the service reaches out quickly if people require additional support with comments including, “There is very good communication, I can’t fault them, they will phone if there are issues and they do listen to what we recommend” and “Staff will contact me if they have any concerns regarding a client and request further input/assessment to help prevent deterioration and prevent decline in mental state.” However, others told us there had been times when support hadn’t been requested in a timely manner. We discussed the concerns with the manager and confirmation was received they will discuss the concerns with the professionals.

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live free from abuse and discrimination.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). The service was making DoLS referrals, although not everyone who required a DoLS had been assessed by the supervisory body at the time of our assessment.However, we found that the provider had imposed a restriction on people without assessing this or ensuring they were agreed as lawful. People didn't have free access to their garden. One person told us they had to ask to go into the garden, with another person telling us there wasn’t enough staff to support them to do this. Two members of staff also told us this. During the assessment the garden works were completed, and we were told people now had free access to their garden, however this had impacted peoples’ quality of life for a number of months.

People and relatives told us they felt safe. Comments included, "I think that [relative] is safe. It’s the first time I could take a holiday and not worry about her" and "He is very safe.” One professional told us, "It's not a home I worry about with safeguarding if something goes wrong.”

Staff told us they had received safeguarding training and understood how to raise concerns, including escalating these internally and externally where required.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a lack of robust oversight and management of risks across the service. People’s risks were not always recorded effectively in their care plans or risk assessments.

Where people were at risk at self-harm, appropriate assessments were not in place including the risk of ligature. Some people had individual escalation plans in place should they become unwell, however these were not in place for others in case of a relapse of their mental health. For another person who had a specific health risk, sufficient control measures and information was not available to guide staff on how to manage this effectively. This meant risks to people were not being managed consistently.

Records and observations did not always demonstrate risk management guidance was being followed. For example, we found 1 person’s risk assessment was not being followed and 1 person’s records detailed they had been offered food that was not in line with guidance from a Speech and Language Therapist (SaLT) on 4 separate occasions.

These concerns reflected a failure to ensure risks to people’s health, safety and welfare were effectively assessed. We discussed the concerns with the management team who started to rectify them during the assessment.

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.

People were at risk from environmental hazards that had not been identified and safely managed through the provider’s own systems.

We found areas of the service were in a state of disrepair and required attention. This included stains on ceilings and flaking paint. We also identified some bathroom radiators and sinks had exposed piping which could potentially cause a risk of burns if a person fell against them and the radiator was on. The pipes were covered during the assessment.

Fire safety arrangements were not robust. People had Personal Emergency Evacuation Plans (PEEP’s) in place, but these were not always accurate. Routine environmental checks of systems and equipment were undertaken; however, the provider had failed to rectify shortfalls within required time frames that were found during fire risk assessments completed in January 2025 and March 2026. This placed people at risk. We discussed the concerns with the management team who started to rectify them during the assessment. We also contacted the local fire service regarding our concerns.

The provider had identified some remedial works that were planned or already in progress prior to our assessment. These included fire safety-related works, a programme of redecoration and improvements to the garden fencing.

The provider did not always make sure there were enough staff.

We received mixed feedback from people, relatives, staff and professionals regarding staffing levels. People and relatives told us, “In the past they would have popped into the lounge and say hello, are people alright, now they don’t, or not as much as they used to, they don’t have enough time" and "They need more staff at the weekends.” One staff member told us, “We are always short staffed, I rarely see enough staff.” Another staff member told us on the day they were spoken to that due to staffing pressures they had, “Only done 1 bath today but should have done 2.” Two professionals told us during their visits, whilst they were in communal areas they did not see any staff present. Another professional told us staffing levels had been reduced which had impacted staff morale at the home.

The service used a dependency tool to determine staffing levels. Staff told us this was not accurate and people required more support than what was detailed within it. Examples of this were given and included someone needing to always be in the lounge and having to support people within the garden. One person told us they must ask to go into the garden to have a cigarette, with another person telling us there wasn’t enough staff to do this. Two members of staff confirmed this.

However, other people and relatives told us, "There definitely appears to be enough staff, and often there is a member of staff in each of the lounges" and “I think that there is enough staff.” Other staff told us, “It’s fine most of the time” and “I feel we’re fine at the moment and everything gets done.”

Staff were recruited safely and received training. Recruitment processes included pre-employment checks such as references, employment history checks, and Disclosure and Barring Service (DBS) checks.

Staff training was mainly up to date, with additional training booked in. Some staff spoken with were not aware when applications had been submitted to authorise a person being deprived of their liberty. We were told staff will be receiving additional dementia, person centred care and DoLS training.

The provider did not adequately assess or manage the risk of infection.

Parts of the environment were in disrepair, with broken flooring and worn surfaces that could not effectively be cleaned. The home required redecoration. The environment and furniture was tired, paint was peeling from surfaces and woodwork was chipped. This increased the risk of infection transmission. We discussed the concerns with the management team who started to rectify this during the assessment and an action plan was received.

The provider had a planned programme of redecoration and improvements which had started prior to our assessment. This included some bedrooms and the bistro area undergoing redecoration and further quotations received for redecoration of communal areas, new furniture had also been purchased for the home.

Staff received infection control training. Staff had access to the personal protective equipment (PPE) they required and were observed to be wearing this throughout our visits.

The provider did not always make sure that medicines were managed safely.

Improvements were needed to the way creams and external items were recorded, to be able to show that each preparation was being applied as directed. Risks had not always been individually assessed for some higher risk medicines such as flammable topical preparations, and anticoagulant blood thinners.

Regular medicines audits took place, and we saw that action was taken when areas for improvement had been identified. However, the audits had not identified some of the areas for improvements we found. We discussed the concerns with the management team who started to rectify them during the assessment.

Staff had training and competency checks to make sure they gave medicines safely. Any errors or incidents were reported and investigated, so that systems could be put in place to prevent them recurring.

We saw people being supported with medicines in a caring way, with people asked if they needed any ‘when required’ medicines. People were encouraged and supported to self- administer their medicines if appropriate. There were suitable processes in place to make sure this was safe for them.

If medicines were prescribed to be taken ‘when required’ there were person centred protocols and care plans in place to guide staff when these might be needed.

There were suitable arrangements for ordering, storage and disposal, including for medicines needing cold storage and those requiring extra security.