Cedar Court Care 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 inspection we rated this key question Inadequate. At this inspection the rating has 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.

At the last inspection, the service was in breach of regulation in relation to good governance. At this inspection, we have found the service is still in breach of regulation of good governance.

This service scored 61 (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 always understand the challenges and the needs of people staff and their communities. The provider was implementing measures to improve the service. This included improving the building, eradicating the issues with pest control, and eliminating an alleged closed culture. The management team was facing many challenges in relation to the changes for improvement they were trying to make. We saw evidence to support some staff were not happy with the changes and did not feel they were being listened to. This led to a high level of sickness and a high level of staff leaving the service. Some relatives had told us they felt there had been a drop in staff morale. We discussed these issues with the management team who acknowledged they had a lot of work to do to bring all staff on board. On inspection, we saw a diverse workforce, and recruitment files we reviewed evidenced recruitment was completed on a fair and open basis.

Not all leaders showed they always understood the context, displayed the skills, and credibility to lead effectively. Some people and their relatives fed back that concerns are not always addressed quickly by the management team involving the loss and misplacement of people’s personal items.

While some incidents and hospital admissions were notified to CQC, we found some which should have been notified were not. We discussed this with the management team and clarified that not all incidents and hospital admissions needed to be reported to CQC, however, when we pointed out incidents of which CQC should have been notified, their response did not assure us there was a clear understanding around regulatory responsibilities in relation to notifications that should be submitted to CQC or external organisations as required.

Accidents and incidents were documented however, measures to prevent further occurrence and/or lessons learned were not always documented. This put people at the avoidable risk of repeated accidents and incidents within the service.

The service had targeted supervisions in place. This meant the manager would check and discuss an element of care knowledge with staff, for example consent to care. However, on inspection, we spoke to staff who were not able to briefly explain the principle of the MCA, and we saw staff supporting people with their meals in an unsafe manner.

Audits and reviews of care plans were in place. However, these did not pick up on some of the concerns we found in relation to some care plans not being person centred, and some risk assessments not having enough information on how to manage individuals complex care needs.

The provider fostered a culture where staff could speak up, and their voice would be heard.

We saw evidence through minutes of meetings to support that staff were able to speak up and express views they had on the service. Staff were able to challenge the management team and put their ideas forwards. We saw a lot of negative feedback from staff, which managers took on board for consideration for improvement. Despite this, the provider had work to do to ensure communication with staff, and the culture of the service was more positive. We saw minutes of meetings which evidenced staff were able to speak up during meetings, and challenge management in an open forum. We received no feedback and saw no evidence to support people or staff were concerned of reprisals for speaking up.

The manager had an open-door policy, which enabled staff to approach with views or concerns if they wished to do so.

The service had a whistleblowing policy in place to support staff with speaking up. Contact information for the complaints, and local authority safeguarding team was displayed in a public location in the service so staff would be able to make contact without the knowledge of their managers if they felt the need to do so.

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. At the time of the inspection, the management team were receiving push back from some staff members about the changes being implemented to ensure equality and inclusion for all staff in the service. The management team recognised they had work to do in this area to ensure all staff felt there was equality across the workforce.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. While there were audits and systems in place to govern the oversight of the service, these did not pick up and address some of the issues we found on inspection. For example, while building checks were carried out on a regular basis, they did not pick up on the broken tap we found in the shower room, nor did it address the odour we noticed from 2 of the shower rooms. We also saw a broken door, and this was not picked up and addressed before the inspection.

Staff received supervision sessions which included checking their knowledge in areas of care and support they delivered. However, when we spoke to some staff at the inspection, they were unable to give a brief explanation of the Mental Capacity Act 2005 and the impact this would have on people. This left people at risk of being supported by staff who did not fully understand how to support them with their independence, choice and control. We discussed this with the management team, who advised us they would investigate this to ensure improvement.

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. Health professionals told us they had positive experiences of working with the service. One health professional said, “Staff are approachable, collaborative, and demonstrate a clear commitment to [people’s] wellbeing. They are generally responsive and open to feedback which supports effective joint working.” There was a lot of communication between the service and the local authority, working towards improving the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.At the time of the inspection, the last staff survey and people survey was completed in April 2025. Issues listed that people had raised were, around the overall cleanliness of the home, concerns with odours in the home and the décor of the home being tired. While at the inspection we found measures had been taken to address these issues, we still found concerns with odours within the home and the décor of the home being tired. There was some issues with cleanliness which also needed to be address. Indicating that learning and improvement off people’s feedback needed to be improved.

While the service did log accidents and incidents, the recording of lessons learnt were not effective, and provided an excuse as to why the incident may have happened, rather than measures to prevent repetition of an incident. We raised this with the management team, who explained the rationale behind the recording, but we were not assured sufficient understanding of lessons learned in relation to preventative measures was understood.

The service had a staff of the month award, where each month a member of staff would receive recognition for their hard work and dedication. This would be recognised via feedback from colleagues and people using the service.