Cedarwood House Care 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 requires improvement. At this assessment the rating has remained 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. The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents had been reported and recorded appropriately and steps had been considered to minimise the chances of recurrence. For example, a person who had experienced several falls had their risk assessment reviewed, and some actions were taken such as increased checks and introducing a sensor mat. Referral had been made to the local authority falls team and rehabilitation team. A medicine review had been requested. A more comprehensive report was produced later in the assessment process that indicated that a medicines review had taken place. All reports were overseen by the manager and attempts made to identify if there were any trends or themes. Staff told us that they received feedback about lessons learned when things went wrong. A staff member told us, “We hear at handovers but also have regular catch ups.” Relatives told us that communications had improved in recent months and that they felt informed when incidents happened.

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. Processes and procedures were in place to ensure the smooth and safe transition of people moving on from the service either for a short term stay in hospital or for a longer term move when the service could no longer meet people’s needs. The manager told us that copies of care plans would go with the person along with hospital administration forms. The latter were found in places to be incomplete, but this was highlighted to the management team and rectified. Professionals told us that communication was positive with the service which helped with smooth transitions for people. One professional said, “The Cedarwood team appear prompt in either directly requesting help from ourselves or getting input from allied health services, occupational therapist dieticians etc.” A relative told us that their loved one had a stay in hospital after breaking their hip. They said the manager was very careful to make sure all the support and equipment was in place before they accepted them back.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment,abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. The manager told us that when they took over a few months ago there were several capacity assessments and Deprivation of Liberty Safeguards (DoLS) missing. They had worked hard to update this area of work but there remained some areas that required review and updating. Some decision specific assessments were in place for example, consent to receive medicines but others were missing, for example, consent to personal care. Staff had been trained in mental capacity and dementia, but some could not recall all the detail of this training. Within care plans there were some details of meetings where decisions had been agreed, made in people’s best interests. The provider shared concerns quickly and appropriately. People lived safely at the home protected from avoidable harm. People told us they felt safe and comments from relatives included, “Yeah, mum is dealt with well and she is safe” and “Yes she is safe and I think all of the risks are covered.” Staff had been trained in safeguarding and were able to tell us the issues that would amount to a safeguarding. One staff member explained, “Sexual, financial, verbal, emotional abuse. If I see something not quite right, I would report to management. I’d always report.” Not all staff remembered who they could report safeguarding issues to although they all told us they would inform a line manager. There was a whistleblowing policy in place and staff told us they were confident to use this process if they felt were at risk. Whistleblowing provides legal protection to staff wanting to remain anonymous when raising concerns. Despite staff being stretched to achieve their daily tasks we did observe staff supporting people when there was an immediate need for example, people wanting to move from one room to another who needed help to transfer, were supported as quickly as staff were able to. A safeguarding policy was in place and the manager had a positive working relationship with the local authority safeguarding team.

The provider did not always work well with people to understand and manage risks. Risk assessments were in place for people for known risks. However, there were gaps in care plans, not all sections of risk assessments had been completed and instructions to staff were not always clear. In nearly every care plan sections around pain management and indicators were blank. Some people were nonverbal, and it was unclear if they were feeling unwell or in pain, how they would communicate this. Some people lived with insulin-controlled diabetes. Risk assessments were in place but some instructions to staff were lacking in detail and simply referred care staff to supervisors and not providing any detail of immediate actions to take. Another risk assessment for a person stated they were unable to use the call bell or a pendant alert. But then went on to conclude that call bell was appropriate to be used. Staff told us that although key information was passed to them at handover meetings and that generally they felt informed, they seldom had time to sit and read care plans and risk assessments to see if there were any changes or updates. Since the site visit the provider has completed and updated some risk assessments.

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.The ground floor of the home had been recently decorated however the rest of the building needed re-decoration and some modernisation. Maintenance staff were tasked to complete this work but advised us it would take a long time before it was finished. There was no wet room on the ground floor, a shower was in use but no bath, although there were plans to have one installed. There were some environmental hazards that we noticed for example, a bedside lamp cover was old, worn and was peeling on the inside of the shade, presenting a potential fire risk. In another bedroom we saw a broken towel rail part of which was sticking out from the bathroom wall. These issues were highlighted to the manager who in turn spoke with the maintenance team to prioritise repairs. Maintenance tasks were logged in a book and dealt with in order of priority each day with larger issues being contracted out. In date certificates were in place for gas, electric and legionella. A recent fire survey had highlighted several actions, and these were being worked through in order of priority. Personal emergency evacuation plans (PEEPs) were in place and were up to date and were accessible in the event of an emergency. Everyone we spoke with told us that the grounds, garden area of the home was lovely and that during the summer months people enjoyed spending time outside.

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. They did not always work together well to provide safe care that met people’s individual needs. There were not enough care staff on shift to support people. This was a particular issue during the morning and early afternoon shift. Staff told us that only 3 care staff at these times were not enough to meet people’s needs. One said, “Most people when they first arrive here are 1:1 with their needs but most now are 2:1.” People’s support needs had increased over time, but this had not been reflected in the dependency tools being used. Dependency tools consider people’s needs and the number of staff then required to meet those needs. During a morning visit we saw the domestic staff, administration staff and the cook, all helping in communal areas supporting people with their needs and requests. They all told us however, that this was not their primary role and it took them away from their core work. All staff told us staffing numbers was a concern and some relatives told us they had noticed how rushed staff seemed at times. One relative said, “Not always enough staff, they are pushed to do everything, lots going on, [staff] are running round, and they need more. I visit 4-5 times a week.” The issue was first highlighted at a team meeting in May 2025 when the deputy manager requested more help. This was acknowledged by the manager and at another team meeting in September 2025 it was agreed that an additional member of care staff would be used for day shifts. At the time of our assessment however, this was not routinely happening. There was some dependency on agency staff, but the manager tried to use the same staff for continuity. However, a relative said, “Not so many new staff now as agency, that’s a little concern for me with the changes of staff.” Staff had been recruited safely and had been through an induction process that included working shadow shifts with more experienced staff before then working independently. Ongoing support for staff was in place through regular supervision meetings. The home was relatively small, and staff told us they felt able to speak to managers for help, support and advice whenever needed. Staff had received training and refreshers however they could not all recall some of the training they had completed. A relative highlighted that they felt dementia training should be prioritised and updated as not all staff seemed to know how to support people as their dementia journey advanced. This was acknowledged by the manager who agreed to prioritise this area of training. Spot checks, unannounced practical supervisions of staff and medicines competencies, were regularly carried out by managers.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. There were 2 housekeepers employed covering 7 days every week. Each worked 4 days for 6 hours a day and so 1 day a week there were 2 at work. We were told however, this was not enough to keep the whole home clean and when working alone, there was not enough time to clean thoroughly throughout the service. We also saw domestic staff taken away from their core duties to help carers support people. Staff told us they had raised these issues but that nothing had changed. The home was superficially clean, but some areas appeared not to have been cleaned for a while, especially on higher floors. Staff received training in infection prevention and control (IPC) and there was enough personal protective equipment (PPE) at the home for staff to use. We saw staff wearing PPE appropriately. The laundry room was clean and well ordered with individual baskets for each residents clothing. IPC and PPE policies were in place.

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. Medicines were stored, administered and recorded safely. We observed a medicine round, and the medicines trolley was kept locked in-between separate administrations by a dedicated staff member who wore a red tabard to ensure they were not distracted or taken away from the round. Medicine administration records (MAR) were colour coded and had a separate key to show successful administration, refusals, or non-availability. These were signed by the medicines giver and where controlled medicines were given, counter signed by a second member of staff. Staff gave people their medicines carefully and with kindness, explaining what they were for and taking time to support people with drinks afterwards as appropriate. Fridge temperatures were checked by staff and recorded. All staff were trained in medicine administration and received regular refreshers and checks on their competencies. Separate policies were in place for as and when required, PRN, medicines and staff were able to tell us the process followed when people requested additional medicines for, for example, pain relief. Relatives told us they were kept informed about any reviews or changes in what their loved ones were receiving.