The Cedars Christian Residential 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.

This is the first assessment for the service under this provider. This key question has been rated Good: This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Information was used to ensure lessons were learnt and, where needed improvements could be made to the service. The provider monitored and analysed the incident and accidents that occurred in the home to see if there any were any trends they could identify. They would then use this information to see how things could be completed differently in the future.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

There were processes in place to ensure people’s needs were assessed before they started using the service. People had lived at the home for a long time. We saw care plans and risk assessments were developed based on people’s assessed needs. Staff confirmed they were aware of people’s needs and reviewed this information to ensure they delivered care in line with this.

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.

People appeared comfortable. One relative told us, "I feel [person] is safe there. I've never ever seen anything untoward."

There were systems in place to ensure safeguarding concerns were identified, reviewed and investigated. Staff told us they had received training and were able to tell us how to report and recognise potential abuse.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and hospitals, this is done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which form part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The service worked within The MCA and upheld people’s liberty.

The provider worked with people to understand and manage risks. Staff provided care which met people’s needs, was safe, supportive.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs in a safe and supportive way, enabling people to do the things that mattered to them.

People and relatives were happy with how their risks were managed. One relative told us, "The manager has shared the risk assessment process numerous times. They have done as much as possible."

People had care plans and risk assessments which reflected their current needs. These plans considered all the needs of people including, management of oral healthcare, their preferred routines and how they ate and drank. These were reviewed regularly or when changes occurred.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found the provider had systems in place to help maintain a safe environment. The service had a fire risk assessment in place, alongside arrangements for the monitoring and maintenance of the environment and equipment. People appeared comfortable in their surroundings and did not raise any concerns about the environment.

The provider had systems in place to ensure there were enough staff available to support people.

People and relatives were happy with the staff who supported them. One relative told us, "Staff are really good, caring and friendly." People we spoke with also described staff as kind and caring and always helpful.

We saw there were enough staff available to support people in line with their assessed needs. Where people had commissioned individual support, they used this to access the community.

Staff told us and records confirmed staff received training. This included mandatory training and training that was specific to people’s individual needs.

Staff had received the relevant pre-employment checks before they could start working with people to ensure they were safe to do so.

The provider assessed and managed the risk of infection. They detected and controlled the risk of outbreaks and took steps to ensure effective control.

There was enough Personal Protective Equipment (PPE) available for staff to use when needed. There were processes in place to monitor Infection Prevention and Control (IPC) to ensure concerns were identified so appropriate action could be taken.

The provider did not always make sure that medicines were managed consistently.

The provider did not always make sure medicines stock was monitored. However, systems were in place to ensure they were safe and met people’s needs, capacities and preferences.

Systems in place to manage and monitor none controlled medicine storage stock was not in place. At the time of the assessment the provider had not recorded the number of medicines stored at the service meaning they did not know if the number in stock was accurate. When raised with the provider they immediately catalogued all medicines stock and implemented a system to ensure stock was accurately monitored and kept up to date.

However, systems were in place to support staff with medicines management, including training, protocols, and audits. Protocols were in place which offered guidance for staff in the use and administration of medicines as well as any associated risks and when emergency services should be called. These protocols required staff to carry medication securely when working in the community.