Cedar Lawn 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 inspection for this service. This key question has been 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 legal regulation in relation to good governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency and understanding challenges and the needs of people and their communities.

Staff felt part of a team. One staff member said, “The registered manager is a very approachable leader.” Another staff member told us, “The registered manager will help with concerns and listens to us.” Relatives were complimentary about the registered manager and staff and felt included in the care of their family members. A relative said, “[The service] is like a family and communication is always open.”

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.  

People and relatives were complimentary about the culture in the service. Staff spoke positively about the registered manager and told us they felt able to ask for support if needed. One staff member told us, “The registered manager has an open door policy, I can always speak to [the registered manager].” Another staff member said, “The registered manager is my role model. [The registered manager] is super good at everything, stress free.” The registered manager was respected and highly thought of by staff at the service.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they knew how to whistle blow and report concerns to external organisations if necessary.

The provider had up to date policies in relation to safeguarding and whistleblowing. The registered manager was aware of their responsibilities and the importance of supporting staff to speak up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were happy in their work.

People’s differences were accepted, and they were supported by staff who understood them.

The provider took a proactive and flexible approach to supporting employees including with their cultural and spiritual needs. This meant staff felt very supported.

The service did not always have clear systems of accountability or good governance.

Governance systems in place were not robust. Audits had not always been used effectively to identify shortfalls we found during the inspection. For example, failing to identify that care plans contained conflicting information.

The provider did not have effective oversight of airflow mattress settings and could not be assured they were used correctly. The provider’s governance framework and processes had not been used to ensure care records, such as daily notes, bowel charts and repositioning records were reviewed and actions taken when required. This placed people at increased risk of avoidable harm.

Monthly management meetings were in place to discuss and review monthly home reports. These did not identify shortfalls we found at the inspection.

The provider and registered manager responded to our feedback by introducing systems to ensure oversight. The improvements made needed to be embedded into practice and sustained.

Services we regulate have a statutory responsibility to notify CQC about certain events that occur in a service. Notifications were being submitted, as required.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

Staff shared information and learning with partners and collaborated for improvement. Staff told us they regularly communicated with health and social care professionals as required to meet people’s needs.

Health and social care professionals were complimentary about working with the service. A professional told us, “I have never been concerned about the safety of any of the residents. The carers have always been very helpful towards myself, and very caring to the residents. It seems well managed. My emails always get a quick response.”

The provider had systems for sharing lessons with staff through regular meetings and discussions.

Staff told us they were supported to learn and improve in their role.

Staff gave us an example of when learning had been shared after an incident and how this affected the way they provided support to people.