The Cedar Grange 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. This is the first assessment for this newly registered provider. However, the new provider inherited the previous rating of requires improvement. This key question remains rated requires improvement. This meant the service 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 the legal regulation relating to good governance. Systems and processes were not effective in identifying the concerns we found during this assessment.

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.

Staff and leaders shared the provider’s vision, strategy and culture. The home had set out values and we saw how these were measured in staffs’ performance and care provided. Staff and the registered manager were honest and open about the challenges the service had faced. The service promoted diversity and inclusion. We found examples where the staff showed they understood people’s personal challenges and adapted the delivery of care in order to effectively support people. The registered manager and provider were open and transparent throughout the assessment, they shared how over the last 12 months they had learnt and developed new ways of working to improve the service, however, these were not embedded in the service at this assessment. Staff we spoke with told us they had seen positive changes happen in the service. One staff member told us, “All incidents are reported and shared, very open and honest. Staff morale is good”.

The registered manager led in a compassionate and inclusive way. The provider and registered manager were visible within the service and led the team by example, this promoted good practices in care. The registered manager actively sourced support from local authorities and other partners which would be beneficial to the service and development in their role. The provider worked closely with the registered manager to provide opportunities to develop and gain skills to lead effectively.

The provider promoted a culture where people felt they could speak up and they would be listened to. Staff participated in regular team meetings and supervisions. Staff we spoke with told us they felt listened to and where they raised concerns they were listened to, and where needed they trusted action would be taken. Staff knew how to raise concerns outside of the service if they needed to do so.

The provider and registered manager recognised and valued diversity within their workforce. Staff we spoke with told us they felt they were treated with respect and equality. Staff told us they worked well as a team and always helped and supported each other. The service supported staff who needed to work flexibly, and promoted a positive work, life balance.

The provider’s governance systems were not always effective. Audits were completed monthly by leaders but failed to identify the gaps we found during our assessment. For example, where medicine stock was incorrect, environmental safety concerns. The provider’s systems had also failed to identify that care plans did not always contain the information staff needed to keep people safe and that care plans were not always being followed. For example, people’s care plans around diabetic care were not always followed by staff as planned. The provider’s systems had also failed to identify that care was not always planned and delivered in line with best practice guidance, such as NICE guidance. For example, NICE guidance for COPD and Diabetes was not always incorporated into people’s care. However, the manager was responsive to our feedback throughout the assessment and explained the newly implemented electronic care records system required further improvements to ensure care was planned and delivered safely and effectively.

The provider and staff did not always work effectively with partners. Feedback we received from partners was mixed. The local authority quality team had an action plan in which they jointly worked with the registered manager and provider to improve the care delivered. The local authority did feedback the concern of ongoing safeguarding concerns and staff culture. We explored this during this assessment and found a change in staffing had recently taken place and the registered manager and new deputy manager were more responsive and actioning change within the home.

The provider had systems in place that focused on continuous learning, innovation and improvement. However, these systems were not always effective. Since our last inspection a new provider had taken over the management of the service. Some improvements had been made, and a plan was in place to improve the service further. For example, audits to have a clear oversight had been implemented and completed. Staff we spoke with, told us about the improvements in practice since the new provider had taken over. Whilst we did identify shortfalls during this assessment, the provider was responsive to our findings and acted urgently on key areas for improvement. For example, where we had safety concerns around radiators been exposed, which had the potential of harming people. Appropriate covers were introduced, and this mitigated the safety concern. People, relatives and staff completed regular feedback forms to the service, this included ideas for improvement and provided information of what was working well and what was not working well. The provider had a system in place to ensure people’s feedback was acted on.