Cedar Lodge

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 good. At this assessment the rating has changed to 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 legal regulation in relation to governance at the service.

This service scored 54 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Although we observed a positive culture during our assessment, 1 person told us some staff were "blunt and domineering" and reported feeling rushed. Two staff also told us they wouldn't allow a relative to live at the home as some staff were “slap dash” and “don't care enough.” One relative told us, "They used to be like a little family, it has lost the family atmosphere."

Most staff felt able to raise concerns with the manager and staff spoken with spoke about people respectfully, however 1 care plan viewed did not demonstrate respect for this person. The regional director told us work was being undertaken to improve the culture at the service.

Professionals also raised concerns regarding staff morale. Comments included, "Morale seems to be very low" and "The morale is very low at present. This clearly comes across when talking to staff."

Not all leaders understood the context in which the provider delivered care, treatment and support.

At the time of the assessment, a new manager had been in post for a few months and was in the process of registering with the Care Quality Commission. However, whilst the new manager was proactive, some issues within the home had been ongoing for many months and had not been identified or addressed by the provider.

Staff feedback indicated a period of ongoing change within the service, and although the manager had begun to implement changes, these were not yet sufficiently embedded to ensure people consistently received high-quality care and support. Concerns were raised with us regarding staffing pressures and workload.

Some staff acknowledged improvements had been made. Comments included, “It’s going upwards. We did have a bit of a low, but it seems to be going upwards now, the old place seems to be coming back” and “It has been a tough year with changes in management, I definitely feel it feels much more positive now.”

We received positive feedback from people and relatives regarding the manager. One relative told us, “I feel welcome when I visit. The manager wanders around and says hello, they know everybody’s names and also visitors. They seem passionate about their residents. Considering the manager has only been there 4 months, it is being well managed.”

Staff told us, “[Manager]s’ pretty good, always comes out make sure everyone’s okay. I’ve seen them walking around and checking upstairs, they always check rooms to make sure they’re up to date” and “[Manager’s] lovely, a very good addition I feel. They seem very supportive.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistle blowing policy in place. Most staff felt able to raise concerns and were confident action would be taken. One staff member told us, “I would contact managers. If it’s them or I feel nothing’s happening, I would go up again and again. We have whistleblowing numbers as well.” Another staff member told us when they did raise a concern this was addressed.

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 reported they were treated in a fair and equitable manner, with appropriate support and reasonable adjustments provided as necessary. One staff member shared their positive experience regarding this.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Systems in place were not robust to provide effective management oversight or to drive continuous improvement within the service. There was a schedule of quality assurance systems in place to support the management team review and assess the service delivery. These systems identified some of the shortfalls in the service. However, the system was not fully effective as it did not identify all the concerns we found during the assessment, or ensure issues identified were promptly addressed. For example, processes to ensure people were being supported in a safe environment, were not always effective. This meant there was an increased risk in relation to fire and infection control, and systems in place to update and audit care plans and risk assessments were not effective. This meant the provider could not be assured they would identify, assess and mitigate risks to people’s health, safety and wellbeing in a timely way. We discussed the concerns with the management team who started to rectify them during the assessment.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We received mixed feedback from professionals. One professional provided an example of learning from an incident that was investigated by the service. Another professional told us, “They are always responsive to learning. If they think things have gone right or wrong, they are keen to learn.” However, another professional told us they didn’t feel the home was striving to improve. The manager told us they had spoken with professionals regarding the feedback and some of the concerns were attributed to miscommunication between both teams. The provider told us they were seeking further clarification from other professionals regarding specific feedback. Some concerns remained subject to further clarification and discussion. The manager and provider were committed to engaging in improvement with partner agencies.

The service was starting to work with the local community. One staff member told us, “Residents are here to enjoy their lives as much as they can, to enjoy activities and be part of the community.” We were told the service was starting to invite local groups into the home, for example local schools and scout groups.

The provider did not always focus on continuous learning and improvement across the organisation.

The management team were open to feedback provided during the assessment and took action to address immediate concerns. However, learning was not always consistently embedded into day-to-day practice. Existing audit and oversight systems had not identified or acted on all areas of concern identified during the assessment. This meant the service was unable to use this information to drive improvement or embed learning. The management team was receptive to the concerns we raised. The provider put in a robust plan of action and started implementing this immediately to minimise the impact to people’s safety.