Cedar Lodge Nursing Home

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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff felt supported by the management team and the provider took on board the concerns raised regarding the need to ensure robust analysis of accidents and incidents.

The provider did not always have a proactive culture of safety. Staff acted on individual concerns about safety, but lessons were not always learnt to continually identify and embed good practice.

People were supported by staff who were aware of the systems in place and actions to take in response to accidents and incidents. Where these events took place, they were recorded and acted on individually. However, there was no evidence to demonstrate these events were looked at collectively for any lessons to be learnt. For example, we saw one person had multiple ‘incidents’ documented against their name, each dealt with individually. But the lack of analysis of these events meant potential trends were not identified and lessons learnt which may reduce the risk of these events happening again in the future.

The acting manager was new in post and was currently reviewing systems and processes in place to support service delivery. A new clinical lead had been appointed and had immediately identified areas for action. They told us, “There are RESPECT forms in place, but I am not happy with them, they are just a photocopy and not the original – we need the original.” We saw steps were taken to ensure all RESPECT forms were completed and signed by appropriate parties within a week. RESPECT forms are documents that are used to outline a person’s preferences for emergency care and treatment. This action ensured staff were aware of people’s needs and wishes.

Staff were able to describe instances where they had reported and acted on individual events that took place. One member of staff told us, “Incidents are reported and escalated to the manager or operational manager. Learning has improved significantly under the new management with more openness and discussion during handovers."

Staff reported they were kept informed of the changes in people's needs and information was provided to them regarding any new admissions to the service.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There had been no new admissions to the service recently. Information was sourced to ensure staff were provided with the detail they required to meet people’s needs when they first came to the service. The acting manager was keen to establish safe and effective systems to ensure staff were provided with the full details regarding any new admissions to the service.

Staff told us information was shared with them regarding people’s care needs, and they were kept fully informed of any changes in people’s needs. A member of staff told us, “I read care plans and handover notes to understand people’s needs” and another told us, “Admission information is shared during shifts and documented in care records.”

Relatives commented positively about how information was shared with them and confirmed they were kept informed of any events regarding their loved ones. One relative told us, “With the change in managers [person] now has a key worker. We like that. They keep in regular contact with us. Leadership is good. We are happy with everything there.”

During the assessment, we observed a handover between shifts which was comprehensive and informative.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe. One person said, “All the staff make me feel safe. They are all really nice. They are all really kind. They do what I ask them to do. They are alright.”

A relative said, “They [care staff] always keep [person] safe. I have no problems with safeguarding.”

Staff spoken with were aware of some types of abuse people were exposed to and actions to take should they be concerned a person had been placed at risk of abuse. A member of staff was able to describe the circumstances surrounding a safeguarding concern they had, and the actions taken to reduce the risk to the individual. The provider had been supported by local commissioners to source additional training for staff in this area, to ensure all staff were fully aware of their responsibilities to report and act on safeguarding concerns.

Where safeguarding events took place, they were logged and systems were in place to ensure appropriate authorities were kept informed and notified of events.

Staff were aware of the Deprivation of Liberty Safeguards [DoLS] and what it meant for people. A system was in place to oversee these applications, but the information shared during the assessment was not up-to-date and we noted the provider had failed to ensure notifications of authorisations were consistently submitted to CQC in a timely manner.

The provider failed to ensure staff were consistently provided with information to enable them to meet people’s needs in a way that was safe, supportive and enabled people to do the things that mattered to them.

People were supported by staff who were on the whole, aware of the risks to them. However, care records in use [and readily accessible to staff] at the time of the assessment failed to hold enough information about people’s clinical care needs and the risks to them. Where risk assessments were in place, some lacked information and were not consistently person-centred. For example, despite staff being aware of the risks to one individual linked to a medical condition, there was no risk assessment in place which provided staff with information regarding this and how to consistently support the person safely and effectively. The electronic care planning system held some risk assessment information, but it was difficult to navigate, and information was not consistently recorded under the appropriate headings, making it difficult to find. For example, where a person was at risk of choking following an incident, this information had been stored under a ‘general note’ under nutrition and was not automatically flagged to the attention of staff who supported the person.

Staff were able to describe the risks to people and how they supported them. One member of staff told us, “We make sure we accompany [person] because we don’t want a risk of a fall. The risks are they [person] may stand up quickly and walk very quickly and we will monitor them.” However, this person’s mobility care plan failed to hold this information.

During the assessment, staff were observed interacting with people in a compassionate and patient manner, giving time and clear instructions to support people safely. For example, staff assisted a resident to and from the dining room, providing clear guidance to reduce the risk of falls.

A relative said, “There’s enough staff to keep [person] safe. They keep an eye on them all of the time. [Person] thinks they can still walk. They can’t. They [care staff] keep an eye on them to stop them from falling. They check on them when they are in their room. They leave a sensor mat on their bed so they can detect any change in weight in bed. They know if they are trying to stand up and get to them before they fall. I have power of attorney and they asked me about it first.”

The provider took on board all feedback during the assessment and made the decision to purchase a new electronic care planning system which they deemed would address a number of the concerns that had been raised. The acting manager confirmed the new clinical lead would be working alongside her on a supernumerary basis to ensure people’s care plans and risk assessments were up to date and accurate. They said, “Our current priorities are getting everything on the new electronic care planning system. We have a new clinical lead and they are excellent.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

A number of environmental issues were noted during the assessment. Many of the carpets were stained and worn throughout the home. Some bathroom areas were tired and in need of redecoration/refurbishment, not only to maintain effective infection control, but to create a more pleasant bathing experience for people. On the first floor, an area outside a person’s room, which was used for weighing people, was cluttered.

There was a lack of signage to assist people to navigate around the home and the redecoration that was currently taking place was not dementia friendly. A living environment that is not adapted to the needs of a people living with dementia can cause them to become more confused, anxious and less independent.

We were advised the provider had invested in a number of refurbishments in the home during the last 12 months, including a new roof. The environmental concerns were raised with the provider, and we were told they would be looked at, as a priority. This had no impact on people living at the service.

A relative commented “Everything is always tidy and clean there. Everything is always put away safely. It’ so lovely."

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

People were supported by staff who told us they felt well trained, supported and received an induction and training prior to commencing in post. However, the training in place was predominantly online. The acting manager told us they were looking to source more face-to-face training for staff and were supported by the provider to access this. They had noted staff had completed online training for adults with learning disabilities but were in discussions with the provider to source specialist training for staff to provide them with the right skills and knowledge to provide safe, compassionate and informed care to autistic people and people with a learning disability, such as the Oliver McGowan Mandatory Training on Learning Disability.

We noted several staff had completed a number of online training sessions in multiple complex subjects in one day and there was nothing to assess staffs learning or understanding of those subjects. When this information was shared with the Operations Director, they told us, “I was gobsmacked about staff doing 3-4 training sessions in one day. I want a planned way, not a rushed way, we are here to improve the care side and have knowledge and tools they need. I want a good team of staff who are confident enough.”

Staff competency checks were not consistently taking place, and many staff had not received supervision since July 2025. The acting manager confirmed they were aware of these concerns and had made arrangements to commence supervision meetings with each member of staff, as a priority. Staff spoken with confirmed they had been given dates and times for their supervision meetings with the acting manager.

Following serious concerns raised by Commissioners regarding recruitment and sponsorship arrangements, the provider acted to address the concerns and had arranged for a full audit of staff files. We saw this was in progress during the assessment and where concerns were raised, actions were being taken.

Staff, people and their loved ones all reported there were enough staff to meet their needs. A relative said, “I think there’s enough staff, if we press [person’s] buzzer, they always answer it quickly.” Another said, “I think there’s enough staff. I don’t know them that well yet, but they are all friendly."

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

Cleaning schedules were in place, and we observed the building to be continually cleaned by dedicated members of staff. However, many parts of the building were worn and tired and in need of refurbishment, which reduced the effectiveness of cleaning schedules. Some areas also suffered from an unpleasant odour.

Staff were seen to be wearing PPE but there was a lack of accessible hand sanitiser throughout the building. Arrangements were made during the assessment to address this concern. A member of staff had been identified as the IPC lead for the service with responsibility for ensuring infection control was adhered to. However, at the time of the assessment, they had not been provided with any specialist training in this area to assist them to carry out this role.

People considered their living environment to be clean and had no concerns regarding infection control. One person told us, “My room is very nice and clean. Everywhere is clean.” Another said, “They clean my room every day."

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were supported to receive their medicines by staff who had been trained and had their competencies assessed. Medicines were stored correctly. Following recent visits from Commissioners, an action plan had been put in place to address a number of concerns regarding medicines management. The management team had responded promptly to these concerns and corrective action had been taken.

We observed staff supporting people with their medication, taking their time when administering each medicine. People and their loved ones told us they had no concerns regarding the management of their medication.