Cedar Lodge Nursing Home

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 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 good governance.

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. They did not always understand the challenges and the needs of people and their communities.

Prior to this assessment, Cedar Lodge had been visited by Commissioners from the Integrated Care Board and the Local Authority over several months. Their monitoring visits had uncovered a number of concerns.

The Commissioners had been actively supporting the service to address these concerns. During this assessment we noted a new management team were in place, including a new acting manager. Staff understood the vision for the service and felt supported by the new management team. Staff meetings were taking place and were used to keep staff informed of changes taking place. Staff spoke positively of the improvements being made to the service and were on board with the acting manager’s vision. A member of staff told us, “The ICB came into the home and noticed issues with care plans and quality assurance and since then management have started working on it. We have witnessed changes.” A relative told us, “There has been a turnover of staff recently. Quite a few changes. There’s a new manager. It’s early days yet."

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

Staff spoke positively of the new management team and of the changes that were being introduced in the service. The acting manager was passionate about their role and responsibilities and keen to ensure systems were in placed to enable staff to support people safely and effectively.

The Operations Director and the provider accepted all findings during the assessment and vowed to be more visible and proactive moving to improve service delivery. The Operations Director told us, “We put our hands up re lack of oversight on our side. It has been a learning curve; we took our eyes off the ball.”

One person told us, “I would recommend here. They look after us very well. The staff are nice. I wouldn’t change anything.” And a relative said, “I would definitely recommend here. I would be devastated if [person] had to leave here."

The provider fostered a positive culture where people felt they could speak up, but people’s voice was not always heard

When the electronic care planning system was introduced, prior to the Commissioners visiting the service, the registered manager sought additional support from staff to assist in the transfer of documentation whilst also carrying out their role. They advised they had also raised concerns regarding the effectiveness of the system with the management team. However, despite these concerns being raised, there was a lack of evidence to demonstrate this additional support had been provided to ensure the system was effective and provided staff with the information they required to meet people’s needs safely and effectively.

During the assessment it was noted the electronic recording system was not supporting the service as intended and the acting manager had also voiced their own concerns regarding this. At this point, the Operations Director consulted with the provider and made the decision to purchase a new electronic care planning system, which they considered would meet the needs of staff supporting people living at Cedar Lodge.

We saw staff’s feedback of their experience of working at the service had been sought. Seven completed staff questionnaires had been received, some dated August 2025 and others with no date. Although there were mainly positive comments, some were some negative. There was no overall analysis of these questions or evidence of any actions taken/lessons learnt or follow ups with these individuals.

Staff were aware of the provider’s whistleblowing policy and were confident if they raised concerns they would be listened to.

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.

On the whole, staff told us they felt they had been treated fairly by management and felt the service was a good place to work.

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

There had been a lack of effective oversight of the service. Systems in place to assess, monitor and improve the quality and safety of the service were not robust. Audits in place had failed to identify concerns that came to light during the assessment.

A new electronic care planning system had been introduced but had not delivered on it’s promises and was difficult to navigate and locate information. The provider had failed to plan for, and offer, sufficient support to assist in the effective implementation of this system resulting in the system not meeting the requirements of the service. This resulted in some records relating to the care and treatment of people who use the service being at times, incomplete, inaccurate and difficult to navigate.

The provider did not have effective oversight of the service or audits in place to provide that oversight. They had relied on the ICB and LA Commissioners to identify failings at the service and relied on their support to bring about improvements.

There was a lack of effective oversight of staff training and staff competencies to give the provider assurances that staff were skilled to do the job they were employed to do.

DoLS applications had been submitted but the systems in place to manage these applications were not robust and the provider had failed to submit notifications of authorisations to CQC in a timely manner.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service was supported by a variety of professionals including healthcare professionals and the ICB and Local Authority Commissioners. The new management team were open and transparent throughout the assessment.

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

The assessment identified a failure to focus on continuous learning across the service. There was a lack of effective oversight of the service. A number of areas for improvement had been identified by the ICB and Local Authority Commissioners and the new management team were responding and acting on these concerns. The management team were receptive to all feedback shared during the assessment process and responded immediately to rectify any areas of concern that were identified. The provider was committed to ensuring additional staff hours were allocated to ensure this work was completed quickly and effectively. Action plans were in place to address and act on the feedback received.