During an assessment under our new approach
Date of assessment: 14 and 28 August and 10 September 2025. Cedar House is a residential care home providing support for up to 12 adults with a learning disability or autistic people living with high needs including physical disabilities. A comprehensive assessment was carried out following concerns that had been raised about the quality of care provided. The service supported autistic people and people with a learning disability. The service can support 12 people, however at the time of inspection there were 10 people living at the care home. The service was assessed against the Right Support, Right Care, Right Culture guidance. The provider did not meet the standards expected to ensure respect, equality, dignity, choice, independence and access to community life for people with a learning disability and autistic people.
People were not always kept safe from harm.
There were not enough suitably skilled staff to meet people’s needs.
Staff training and competency assessments were not carried out consistently or appropriately.
Food preparation areas were not hygienic and food was not prepared to meet people’s dietary and physical needs.
The service operated with a closed culture. Incidents were not always reported or escalated, and the provider had not identified the absence of incident reporting. Inspectors saw examples which suggested staff were incorrectly recording information that presented the service as safe.
Lessons from identified issues were not always communicated effectively. Staff did not consistently understand the training they received, which impacted how healthcare needs were met. People with specific health conditions were not always monitored and staff did not always respond appropriately to urgent health concerns.
The environment and lack of clear processes contributed to people not being protected from harm. Care plans and risk assessments did not consistently reflect people’s needs or provide guidance on supporting people when they were expressing anxiety or distress which posed a risk to themselves or others. The Mental Capacity Act was not applied consistently and some people were subject to restrictive practices.
People were not always treated with dignity and respect. There were limited activities to engage and stimulate individuals, and communication methods were not tailored to support understanding.
The model of care did not promote choice, control, or independence. Person-centred care was not consistently delivered, and people’s dignity, privacy, and human rights were not always upheld. Leadership behaviours and attitudes did not support people to lead confident and empowered lives.
Systems to ensure staff were trained, competent and following procedures were minimal. Audits were lacking and those reviewed did not reflect inspection findings.
The Providers own policies which related to medicines, training and staffing were not always understood or followed by the service or the provider.
Governance systems did not identify the concerns found during inspection
At this inspection, the provider was found to be in breach of 7 regulations, relating to person-centred care, dignity and respect, need for consent safe care and treatment, safeguarding people from abuse and improper treatment, governance and staffing . There are continued breaches of regulations which were identified at the previous inspection: safe care and treatment, premises and equipment, person-centred care and governance.
The provider was previously in breach of the legal regulation in relation to person centred care, Safe care and treatment, Equipment and premises and Governance. Improvements were not found at this assessment, and the provider remained in breach of these regulations.
The provider had not learned from previous breaches to improve the service.
A new manager had been appointed and we found they had begun to provide leadership and the oversight around the texture of food and drink to improve people’s safety. However, changes
and improvements were yet to be embedded to demonstrate they were effective.
In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.