Archived: Cedar House

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 has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was previously in breach of regulation in relation to Well led. At this inspection we have found evidence that the provider still needs to make improvements.

During the assessment, we wrote to the provider and asked them to act on the most serious and urgent concerns found. The provider responded with assurances that action had been taken or was planned to mitigate these risks
 

This service scored 29 (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 shared vision, strategy or culture that was designed to enable independence for those in their care or to extend commitment to all aspects of their business.

A regulatory inspection in December 2024-January 2025 found the service had breached regulations relating to safety, medicines, environment and governance. Although the provider created an action plan and gave assurances of compliance, inspectors found that serious concerns remained and continued to affect people’s safety and wellbeing.

Inspectors were not assured that the provider had sufficient oversight of how the service was being managed locally. Systems were not robust enough to ensure staff could perform their roles effectively or that people were kept safe.

The provider promoted 5 core values: friendly, positive, innovative, empowering, and person-centred, but these were not consistently reflected in practice. Although the values were displayed and discussed in meetings people’s care did not consistently embody them. Provider oversight did not demonstrate a commitment to embedding these values in daily operations.

Staffing levels were insufficient to meet the needs of people safely and effectively. The dependency tool used to calculate staffing requirements did not accurately account for the full scope of staff responsibilities and was not followed during night shifts. Staff reported that there were not enough staff members to support those living at the service and inspectors observed that tasks were either not completed or not performed to an acceptable standard.

Inspectors found examples of inaccurate records, which undermined the reliability of care documentation.

There were failures in delivering person-centred care. Inspectors witnessed incidents where people’s human rights were not respected. Individuals were not consistently supported to live fulfilling lives, and care practices did not reflect a commitment to dignity, autonomy or safety.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders failed to embody the values of their workforce and organisation, and did not lead with the necessary skills, experience, or credibility. The provider relied on the registered manager to oversee the service. However, several issues identified during the inspection identified gaps in oversight and leadership indicating further support and scrutiny were needed to ensure safe and consistent care. Although locality leaders had documented concerns and issued actions they were not always enacted or followed up by senior leadership. For example, audits identified concerns with food labelling and vermin beneath a storage shed remained unresolved, placing people at risk.

Following the previous inspection in December 2024, an action plan was developed to address regulatory breaches. However, inspectors found that not all those actions had been embedded into practice and concerns persisted.

Care was not consistently delivered in accordance with individual care plans or service policies. Inspectors observed unhygienic conditions and unsafe management of health needs, none of which had been identified through internal audits.

Managers failed to ensure staffing levels were appropriate or use an accurate dependency tool to calculate requirements. All staff stated staffing levels were inadequate to safely support people.

Management audits were limited and failed to reflect the conditions inspectors observed.

Staff reported raising safeguarding concerns to managers, but these were not documented or escalated. Only 1 safeguarding incident had been logged in the past 6 months and that had been reported externally. The provider had not identified the absence of safeguarding reports which might have suggested a closed culture. Local managers were involved in staff competency assessments and inspectors were not assured of the accuracy of those documents.

The provider had no system in place to ensure staff competency assessments had been completed or were sufficient to evidence safe care for people. We were provided with some documents which showed not all staff had been fully assessed in some areas of training. The provider confirmed that for some areas of care no competency assessment had been made at all. The provider supplied us with incomplete documents (missing pages) for some competency assessments.

The provider did not have robust systems that meant staff were fully trained in mandatory subjects. The provider supplied documents that showed that mandatory training for staff in some cases was 67%.

The provider was unable to provide some documents relating to workforce planning because the Registered Manager had left the service.
 

Most people who lived at the service were not always facilitated to voice concerns, were not supported with alternative methods of communication. Many people did not have an external advocate and interactions with people outside the home were limited.

Some staff said that when they raised concerns during team meetings, no action was taken and documents showed staff spoke up, but the content was not always recorded.

Some staff reported that when they raised issues individually with a manager, they were told to leave the service and as a result they did not feel confident to raise concerns again. Some staff did not feel supported by management and felt there was favouritism and that they didn’t escalate concerns as they had been threatened to be sacked. This posed the risk of creating a closed culture, where staff could not raise concerns freely.

Staff told us they had reported safeguarding incidents, but they were not documented or escalated by the previous registered manager. Staff did not feel empowered to raise matters with other managers.

The service did have a confidential contact line which was displayed in several areas of the home. However, this had not addressed staff concerns about escalating any issues within the organisation.

Some staff told inspectors that recent changes in management had improved openness and made them feel more able to raise suggestions and concerns. This had yet to be embedded in the service.
 

The provider did not always value diversity in their workforce. They did not consistently work towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was no evidence of any processes in place to support staff wellbeing despite staff sometimes working long hours.

Staff reported inconsistency in how concerns raised during meetings were addressed. While some issues were acted upon effectively, others were overlooked.

Some staff said they felt excluded when colleagues spoke in languages other than English and this limited their ability to engage in team discussions and could exclude people who relied on clear communication to feel safe. Although this concern was raised with the manager, no meaningful action was taken to address it, leaving some staff feeling excluded.

Some staff said they were not treated as well as their colleagues when making work-related requests and one staff member said they were told “If you cannot work on that day, you can go.” Other staff said they felt valued and included.

 

The provider did not have clear systems of oversight, accountability or good governance.

At a previous inspection in December 2024, we found systems and processes were either not in place or were ineffective in monitoring quality and ensuring the building, environment, and facilities were clean and safe for people to use. At this inspection, concerns remained with governance systems at both local and provider level. These included failures in managing risk, training, environmental safety, care planning, workforce planning, staff wellbeing, and the consistent delivery of person-centred care.

There was little evidence of auditing or analysis at either local or provider level. The absence of robust governance mechanisms across audits, training, incident management, and complaints raised concerns about the provider’s ability to monitor quality, manage risk, and uphold standards of care. The provider lacked systems to verify the completion of mandatory training or to ensure competency assessments were conducted ethically, thoroughly, and accurately. The training matrix showed gaps in compliance, and inspectors were not assured that competency testing met appropriate standards.

Governance systems failed to identify that the provider had not implemented its delegated healthcare activity protocol. There was a lack of clarity about who was accountable for delegated healthcare tasks and those responsible for delegation were not routinely involved in agreeing staff training or assessing competency to ensure it was of the right level and quality.

The provider did not have robust systems in place to ensure that confidential documents were managed in line with the General Data Protection Regulation (GDPR), which meant sensitive information was not consistently stored securely or handled appropriately. Inspectors found personal care records and confidential paperwork stored in outdoor sheds that were dirty, disorganised and showed signs of vermin activity. This posed a risk to data security and individual privacy.
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not have robust systems in place to identify shortfalls and support learning to make improvements. As a result, staff did not raise issues and if they were the manager did not escalate or report them.

There was a culture of making the service appear that there were no issues or concerns by sometimes wrongly documenting checks or just not raising concerns. The only incidents that were reported internally were documented as clinical concerns and these showed no investigation, learning or improvements made as a result.

The provider had not developed communication strategies tailored to people, most of whom are not able to communicate verbally with words and therefore caused a barrier to people sharing any concerns they might have. The service had not sought meaningful feedback from relatives or staff about how the service is managed or run.

Audits did not accurately document the environment and no reviews were conducted of health monitoring leaving people at risk.

The provider had no systems in place that would identify that staff needed further support and actions seen by Inspectors raise staff understanding and managerial oversight of the training that had been given particularly when those concerns were evident in the previous inspection.
This meant that there were missed opportunities to identify concerns and make changes, despite significant shortfalls requiring widespread improvement
 

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not have robust systems in place to identify shortfalls and support learning to make improvements. As a result, staff did not raise issues and if they were the manager did not escalate or report them.

There was a culture of making the service appear that there were no issues or concerns by sometimes wrongly documenting checks or just not raising concerns. The only incidents that were reported internally were documented as clinical concerns and these showed no investigation, learning or improvements made as a result.

The provider had not developed communication strategies tailored to people, most of whom are not able to communicate verbally with words and therefore caused a barrier to people sharing any concerns they might have. The service had not sought meaningful feedback from relatives or staff about how the service is managed or run.

Audits did not accurately document the environment and no reviews were conducted of health monitoring leaving people at risk.

The provider had no systems in place that would identify that staff needed further support and actions seen by Inspectors raise staff understanding and managerial oversight of the training that had been given particularly when those concerns were evident in the previous inspection.
This meant that there were missed opportunities to identify concerns and make changes, despite significant shortfalls requiring widespread improvement