Archived: Cedar House

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was previously in breach of regulation in relation to people’s safe care and treatment, including failings regarding the proper and safe management of medicines and lack of safety for premises and equipment.

At this inspection we have found evidence that the provider remained in breach of regulation
 

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a culture of safety.
People were not being protected from the risk of abuse, risks were not identified such as the risk of injury from people who lived at the service to other people . Risks and incidents were not reported and analysis and lessons learned were not completed.
We saw minutes of staff meetings which gave some practical advice on supporting individual people, however there was no indication that meaningful interventions such as training sessions or reassessment of staff competency were instigated.
However, a new manager was in place and had documented guidance to staff regarding a safeguarding issue that had occurred. This approach to lessons learned still needed to be embedded, monitored for success and sustained.
 

The provider did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. The service was in breach of legal regulation in relation to people not being protected from the risk of harm, due to poor oversight and unsafe care practices. Care plans did not always distinguish between allergies and intolerances, and some contained spelling errors that could lead to misinterpretation. This placed people at the risk of suffering avoidable allergic reactions. No action had been taken to clarify these issues until inspectors raised concerns. Staff did not follow national best practice guidance or provider policy when delivering care. For example, we observed unsafe catheter care, where a person was not given support as written in their care plan, increasing their risk of infection. Although the provider stated that district nurses were available for support, advice was only sought after inspectors raised concerns. People with epilepsy were not consistently monitored to ensure their safety and in line with care plan guidance. Staff failed to observe people appropriately and monitoring systems such as bed sensors and cameras were not reliably used. This lack of proactive oversight placed people at significant risk of harm and as a result Inspectors created a safeguarding report to the local authority.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

The service was in breach of legal regulation in relation to people being protected from the risk of abuse, neglect and improper treatment . Though staff had completed safeguarding training, inspectors were not assured all staff understood how to report concerns or apply the provider’s own safeguarding policy. Staff responses showed confusion about appropriate safeguarding actions, posing risks to people’s safety. For example, 1 staff member said they would, “Keep an eye” on a colleague rather than report suspected abuse, and another said they would raise concerns with the person involved rather than escalate to management. This posed the risk of a closed culture forming, with concerns not escalated appropriately to external bodies such as the local authority safeguarding team or the police.

Some staff said they were not informed of follow-up actions when safety concerns were raised. A locality manager stated that incident themes were reviewed at provider level, but no safeguarding incidents had been received in the last 6 months , because no safeguarding matters had been reported. Lessons learned from incidents were recorded as staff following procedures, with no evidence of further action, guidance or competency assessment where appropriate.

Where reports had been made to the registered manager, they were not always documented, meaning the provider lacked oversight of potential safeguarding concerns. The provider had not recognised that the absence of reports could indicate underreporting of incidents.

The service did not consistently implement its policy on reducing restrictive practices. Clear guidance for staff was not recorded in care plans and staff responses such as telling people to “stop” were not or assessed for appropriateness.
 

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
Inspectors found people’s care and support needs were not consistently or appropriately risk assessed, placing individuals at risk. Risk assessments lacked sufficient detail and did not provide staff with clear, actionable guidance . We found all peoples eating and drinking plans did not clearly explain which IDDSI International Dysphagia Diet Standardisation Initiative (IDDSI) level people should be given (this describes food textures and drink thickness for individuals with swallowing difficulties ). We saw people given food of a texture that did not comply with the guidance shown in peoples individual care plans.
Many residents had multiple health conditions, yet staff had not been adequately trained or assessed to meet these needs safely. Positive Behaviour Support (PBS) plans were in place but lacked documented outcomes or follow-up actions, limiting their effectiveness in guiding care.
People were not consistently empowered to take appropriate risks that could support independence or personal development. Although care plans suggested involvement in daily activities, inspectors found no evidence these had taken place . Inspectors observed one person on three separate visits whose goal was to make a sandwich and was not supported to achieve this goal.
There were no systems in place, either locally or at provider level, to monitor and manage risks effectively. Risk assessments focused on controlling risks from the perspective of staff, rather than enabling people to build skills or confidence. This approach restricted opportunities for personal growth and did not align with best practice in supporting people with multiple needs to lead fulfilling lives.
 

The provider did not detect and control potential risks in the care environment. They did not ensure that equipment, facilities and technology supported the delivery of safe care.
Inspectors found that the care home was not secure. Side gates were left unlocked and locks were broken, allowing unrestricted access to the rear garden and residents’ lounges from the street. A side access fire door was not alarmed, meaning people could leave the building without staff being alerted. Some bathrooms had broken items which presented a risk of injury to people using them.
The kitchen was unhygienic. Inspectors saw undated opened food items, containers and utensils contaminated with old food residue, visibly dirty sinks, and a metal pan filled with liquid fat inside the oven posing a fire risk. Fresh fruit was stored in a rusty metal bowl placed in a corner of the kitchen.
The thermometer used to measure food temperatures was not working, yet staff had recorded readings for that day, raising concerns about the accuracy and reliability of food safety checks. Staff did not consistently take food temperatures before serving and lacked understanding of why this was necessary. One staff member was observed checking the temperature of a cold cheese sandwich, indicating a lack of understanding of food safety practices.
However, all health and safety checks by external providers were in date and found to be compliant. Inspectors also found that people’s rooms appeared visibly clean, tidy, and free from noticeable odours.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not ensure staff received effective support, supervision or development, and staff did not work together well to provide safe care that met people’s individual needs.

Inspectors identified concerns regarding staffing levels, training and competency, which posed risks to the safety and wellbeing of residents. The service used a dependency tool to calculate staffing needs which did not include domestic tasks such as cleaning and food preparation. Weekend staffing levels were consistently below the minimum that was shown in the providers dependency tool, raising concerns about workforce planning.

Not all staff were sufficiently trained to keep people safe. On night shifts, there was not always a person trained and assessed in administering medication via Percutaneous Endoscopic Gastrostomy (PEG ) this system provides nutrition directly into the stomach for individuals who cannot eat or drink enough by mouth. Staff reported that there were not enough people to complete all required duties, resulting in missed tasks and compromised standards of care. One staff member said, “It’s too much, we have requested too many times for more help, we cook and clean and everything.”

Some staff worked up to 71.5 hours per week, which could impact the quality of care due to staff fatigue. Staff did not consistently understand how to support people with food allergies. One person that the provider documented as having a dairy allergy or intolerance was given food containing dairy.

Training compliance was inconsistent. We reviewed the training matrix and found inconsistent completion rates across mandatory courses, with some areas showing compliance as low as 67%.

Whilst staff received training, they did not have documented competency assessments for key tasks such as administering seizure medication, PEG medication, supporting people to eat and catheter care. This placed people at the risk of harm from unsafe practice in these higher risk areas of care and support. As a result, the provider arranged for staff to be assessed in areas we had identified as a concern.

Inspectors were not assured that competency testing, particularly around Dysphagia, was conducted ethically. We saw written answer sheets which raised concerns about the integrity of the assessment process in that some were written in the same handwriting or gave identical responses.

Inspectors observed unsafe staff practice when supporting people to eat, failure to support people with dysphagia (swallowing difficulties), food not meeting required IDDSI texture levels and providing food that contained allergens to people. Staff did not consistently check food temperatures or ingredients for allergens and liquids were thickened without proper measurement, increasing the risk of choking.

Some staff reported difficulty understanding eLearning modules and relied on colleagues for clarification, highlighting the need for more accessible and inclusive training materials. All staff expressed the need for a dedicated cook trained in nutrition and IDDSI requirements. Some had received no training in food preparation for modified diets, and inspectors found no evidence of competency assessments in this area.

The service has since advertised for a trained cook and confirmed staff have now been competency tested in the areas raised.
 

The provider did not 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.
Inspectors found personal care items and confidential paperwork stored in dirty, disorganised sheds, some of which showed signs of vermin and faeces. This posed an infection risk and showed that IPC concerns raised at the previous inspection in January 2025 had not been addressed by the registered manager.
Personal protective equipment (PPE) was found in a shed that was unclean, some (gloves) were past their expiry date and were found in use in the home. Bathrooms were not consistently clean. Long-standing dirt was observed in cracked floor drains and around skirting boards, along with cracked tiles and loose, dirty sealant in shared toilets. The provider stated that deep cleaning had since been carried out and the drain covers would be replaced, however, this had not been independently identified through the provider’s own systems.
Staff did not consistently support people who use catheters in line with best practice and care plan guidance, placing them at the risk of acquiring infections. Catheter bags were not always emptied promptly or positioned appropriately, posing a risk to people’s health and wellbeing. This meant there was a need for improved staff training, oversight, and accountability in delivering safe continence care. Inspectors reviewed a recent infection prevention and control (IPC) audit which failed to identify issues that were clearly visible during the visit. This discrepancy raised concerns about the accuracy and effectiveness of the service’s internal monitoring processes and undermined the reliability of the audit as a tool for ensuring safe and hygienic care
People’s bedrooms were clean and smelled fresh, and individuals were dressed in clean, appropriate clothing. Medical items used for PEG feeding were stored in a clean, dry environment and were in date. However, as we saw that items used to support Service Users were stored in unhygienic sheds, this meant we were not assured people were safe from the risk of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
Medicines, including controlled drugs, were stored securely and at appropriate temperatures. However, some people were given medicines covertly mixed with food, with no clinical oversight and this was not always recorded on the medicine administration record (MAR). Some medicines may not be suitable to be crushed or mixed, potentially reducing their efficacy or placing people at the risk of overdose . This did not provide assurance that medicines were administered in line with people’s assessed needs or legal safeguards under the Mental Capacity Act 2005 for the administration of covert medicines.
Staff had received training in medicines administration and specialist tasks such as seizure management and PEG feeding. However, inspectors found that overnight rotas relied mainly on agency or bank staff who did not always have specialist medicines training. This meant that if a person required PEG administered medicine overnight, there may not have been a trained staff member available, posing a significant risk to safe care.
Some people were prescribed medicines on a “when required” (PRN) basis. Inspectors found that several PRN protocols were not in place or were not person-centred. In some cases, the stated dose differed from the GP’s prescribed dose, raising concerns about the accuracy and safety of medicines administration.
Inspectors also observed that some prescribed medicines were not being used in accordance with GP instructions, raising concerns about the safe and appropriate delivery of personal care and the service’s adherence to medical guidance..