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 assessment we rated this key question requires improvement. At this assessment the rating has remained 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 management, leadership and governance at the service.
 

This service scored 50 (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.
A clear vision and culture was not always evident. Although people were mainly happy with the care they received and said they felt safe and staff were kind, the concerns found during the inspection did not evidence a shared vision and goal to provide safe and good quality care. Staff were not always working well as a team, and the provider had not led with good communication in relation to their vision for the service. There was a lack of clarity and understanding of what the aims of the service were and who they could and should provide a service for to ensure equity and equality.

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.
There had been a number of interim managers over the last 2 years which had impacted the leadership and culture within the service. A new manager was in post who was in the process of applying to register with CQC. However, there were a number of cultural issues that needed to be addressed and improved to ensure improvements were made to the quality of care. Staff were discontented and there were concerns within the service that had not been considered or acted upon quickly, leading to a lack of assurance in relation to effective leadership.
People and their relatives said they liked the new manager, felt they could approach them, and hoped they would make improvements.

Staff did not feel they could speak up and be listened to. People did feel they could speak up and that their voice would be heard.
Staff told us they knew they could speak up if they had concerns about people’s safety. However, multiple anonymous whistleblowing concerns were raised externally with the local authority and CQC in relation to staffing concerns, including being short staffed and a reduction in staff contracted hours. Staff had not felt they would be listened to by the provider so had taken their concerns outside of the service.
People and relatives were confident they would be listened to if they raised concerns. They told us they knew who they would speak to if they were worried.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.
Staff did not feel they were valued. They told us they felt they had not been treated fairly and their voices were not heard. Staff were concerned new staff had been recruited just prior to the staff team’s contracted hours being reduced and felt this was not fair. The provider had needed to act due to the reduction in the number of people living at the service. However, this had not been communicated well to the staff team leading to a feeling of inequality and unfairness.

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.
Governance arrangements for auditing and monitoring the quality and safety of the service were in place but were not robust and proved ineffective. The concerns we found in relation to inconsistency in the quality of care plans, risk management and consent to care were generally not picked up. Auditing had not picked up the disrespectful descriptions and guidance in some people’s care records and missing crucial information about people’s past lives. The management team and staff had not identified the needs of people living at the service who had a learning disability, and whether they were meeting their needs. The local authority had not been approached to undertake an assessment to ensure their needs were being met or could be better met elsewhere. The provider undertook a 3 monthly audit but this did not evidence clear oversight or a robust approach to checking quality and safety as improvements needed had not been identified. Opportunities had been missed to improve the standard of care by ineffective quality assurance.

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 manager and staff engaged with community healthcare staff to support people’s health needs and benefit their health outcomes. There was limited engagement with other external partners to share ideas and gain added support to improve and innovate. However, the manager had been in post for a limited time and had spent time dealing with issues in the service. They told us they planned to join local networks and forums as soon as they were able to.

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.
A learning culture was not always embraced to ensure prevention and safety. Accidents and incidents were monitored regularly but were not always effective in learning lessons to prevent further occurrences. Although lessons learnt were recorded on the monitoring form, these were generic and did not always address the learning from the specific incidents in the that period. There was no process for cascading the learning to staff to ensure they had access to the findings of incident monitoring and the necessary guidance in prevention.