The Cedars Christian Residential 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 the service under this provider. This key question has been rated Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture.

Most staff spoke positively about the culture of the home and told us the provider fostered a positive culture. This included ensuring the wellbeing of staff and ensuring staff received training to give them the skills and knowledge to promote a positive culture. The registered manager told us about the direction and culture of the service. They described their commitment to providing person-centred care, promoting people's independence and ensuring people were treated with dignity and respect.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

People and relatives spoke positively about the registered manager and how the home was run. One relative told us, "Both the manager and deputy are very approachable to discuss any matters." People living at the home also spoke positively about the management team and told us they knew who the registered manager was. One person expressed their confidence in the manager telling us, "The registered manager knows what they are doing."

There were systems in place to ensure staff and the registered manager understood their roles and responsibilities. The management team demonstrated oversight of people's care and worked proactively with healthcare professionals to help ensure people's changing needs were met. Professionals spoke positively about the leadership within the service and described the deputy manager as knowledgeable, approachable and understanding of people's individual needs. This helped to promote positive working relationships and effective partnership working.

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

There was a whistleblowing policy in place. Staff we spoke with were aware of these procedures and the action they needed to take if they had concerns.

The provider valued diversity in their workforce.

There were procedures in place to consider staff members’ individual needs, including their diverse needs, and to ensure all staff were treated fairly and equitably. Staff raised no concerns with how they were treated.

While staff feedback was generally positive, one staff member expressed concerns regarding management oversight and felt activities taking place during the inspection were not always representative of normal practice. We considered this alongside feedback from other staff, people, relatives and our observations during the assessment and did not identify any additional concerns to indicate this was a wider issue within the service.

The provider did not always have effective systems of accountability and governance in place to assess, monitor and mitigate risks. Whilst systems were in place to monitor the quality and safety of the service, these were not always effective in identifying areas requiring improvement.

During the assessment, we identified concerns regarding medicines stock monitoring that had not been recognised through the provider's existing governance processes. Whilst information relating to medicines management was collected, stock records did not consistently record the quantities of medicines that should have been available. This meant stock reconciliation processes were not sufficiently robust to provide assurance medicines were being managed or stored safely. Although we did not identify any medication incidents during the assessment, the provider could not be assured discrepancies would be identified promptly, as the monitoring systems in place were not effective in detecting potential concerns.

Despite this, the provider had governance arrangements and oversight systems which were used to monitor other aspects of the service. Family members spoke positively about the management of the home, with one relative telling us, "It's definitely a well-run home." Records demonstrated accidents and incidents were reviewed and analysed to identify trends and opportunities for learning, with actions taken to reduce the risk of recurrence. The registered manager responded positively to the concerns identified during the assessment and took immediate action to address the medicines monitoring issue, demonstrating a willingness to learn and improve.

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

There were systems in place to ensure the provider worked in partnership with other agencies. The registered manager gave us examples where they had made referrals to other professionals for advice or support. Professionals told us the service had increasingly taken responsibility for making referrals directly when people's needs changed, including referrals to specialist services such as speech and language therapy. We also saw evidence of the service working with GPs, the falls team and other healthcare professionals to monitor people's health needs and support positive outcomes. Professionals spoke positively about their working relationships with the service and the responsiveness of the management team.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

When incidents or safeguarding concerns occurred, the registered manager ensured lessons were learnt and actions were taken to reduce the risk of reoccurrence. The management team worked proactively with external professionals and demonstrated a willingness to seek specialist advice when people's needs changed. Professionals confirmed that where there had been concerns raised previously the service had taken listened to feedback and made changes to the way they worked with external services.

Additionally, leaders were receptive to feedback and suggestions for improvement provided during the assessment and demonstrated a willingness to reflect on practice and make changes where required.