Cedar Grange

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 changed to 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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service had a clear vision and values that staff understood and worked towards. Staff described the home as “a good team” and said they felt part of a family. The registered manager produced “you said, we did” boards after analysis of surveys and meetings to emphasise a collaborative involvement in the service. A staff member said, “Management trust us and carry us along.” This approach fostered a sense of shared responsibility and commitment to person-centred care.

The provider 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.

The registered manager was described as approachable and supportive. A staff member confirmed, “From the [registered] manager to the administrator, they are really, really nice and approachable”. Leadership had improved since the registered manager took over, with consistent follow-through on actions and strong support from regional managers. Staff told us they felt the registered manager was fair and focused on safety across the home.

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

Staff told us they felt confident raising concerns and were listened to. Whistleblowing routes were displayed on staff notice boards, along with union information. Regular staff meetings took place where staff told us they were able to freely discuss all aspects of the service and felt they would be listened to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt they were treated equally and were supported equitably without any discrimination. Staff from diverse backgrounds spoke positively about inclusion.

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 systems were in place. Audits were completed when scheduled and key performance indicator reporting was shared with the provider. However, these had not always been effective. For example, care plan audits were sporadic, and ‘resident of the day’ sheets were barely completed. This meant there was a lack of purpose to their completion. These audits had failed to identify the issues found during our inspection visit, for example, gaps in care planning and environmental checks. The registered manager told us there had been a primary focus on the transition to electronic care planning and acknowledged further work was required to improve oversight.

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 service worked in partnership with health professionals and the local authority. We saw evidence of engagement with community activities, including planned visits and events such as a Christmas fair. However, attendance at residents’ and relatives’ meetings was low, and it is suggested the provider explore ways to improve participation.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider demonstrated a commitment to improvement. The registered manager was proactive in addressing issues, for example, implementing new audits on the electronic care planning system and introducing structured huddles. Staff shared ideas for improvement, such as adjusting how people were supported to the toilet, which reduced delays, which were adopted. A staff member told us, “I had a brainwave and spoke with [the registered manager] and now it works better.”