Cedar Lodge

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 good. At this assessment the rating has remained 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 leadership at the home and staff contributed to a culture at the home which was focused on providing good care to people.

It was clear there was a positive, ‘no blame’ culture and a culture that learnt from incidents to improve people’s experiences at the home. The registered manager took their role and responsibilities seriously and people and relatives feedback to us, showed the registered manager was an important and integral part to the home’s improvements. Staff worked closely with each other, senior and clinical staff and management to provide the best care outcomes.

One staff member told us, “I really, really like working here. Our management and colleagues are very good. Colleagues take time to explain things, why you need to do things in a certain way.” Another staff member said, “The best thing is caring for residents, [people], and the families. There’s continuity, so you can learn lessons, such as about hand hygiene. We have always been open and honest with the relatives. [Registered manager] wants the best for people. She regularly meets and greets and is kind to [people].” A further staff member said, “I am proud of the atmosphere here. It’s homely and residents are looked after well.”

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.

Everyone we spoke with who received a service and the staff team, were complimentary of the registered manager. People and relatives said the culture at the home supported really positive care outcomes. In the communal hallway of the home, a board was displayed of compliments from people and families. Comments included, “I became her daughter again, not her guardian”, “The home provides such a warm and affirming culture” and “She had nothing but the best and kindest care from everyone.”

A culture had been fostered where people’s relatives were seen as partners in their care. This encouraged relatives to be part of their family member’s day to day lives, for example, to join in with moments of happiness [dancing] with their loved ones. A staff member gave us an example of how relatives were kept up to date with events in the home, such as a pyjama day undertaken by staff. A notice had been put on a notice board, so relatives were made aware. One staff member said, “[Registered manager] talks to me and asks how everything is.” Another staff member told us the registered manager included all staff teams when considering people’s care and said, “She [Registered manager] wants people to have a place they can call home and have person centred care. She nips friction in the bud, and she wants residents to have a good quality of life and for relatives to be supported.”

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

Staff were confident to speak up and share concerns and suggestions. Staff said the registered manager was approachable and they had opportunities for speaking with them to share any feedback. Staff were positive about the way they were led and told us they felt empowered to raise any concerns directly with senior staff. Staff had received training in relation to whistleblowing, in the event they wished to raise any concerns outside of their immediate management.

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.

The registered manager told us, “My staff team are of the utmost importance to me. I recognise that they are individuals first, and when they experience significant life events both positive and challenging, I strive to support them in a meaningful and compassionate way.” They gave us examples how they had personally supported some staff during difficult times. Where some staff had experienced bereavement, the registered manager ensured staff were offered appropriate bereavement leave and signposted to professional, free support services and wellbeing programmes available through the provider. A staff member gave us an example showing how their own family caring responsibilities had been supported by the registered manager who allowed them to work flexibly to meet their own caring responsibilities. The registered manager said they facilitated staff to take time off for health appointments.

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.

The provider had a structure for providing oversight of audits and checks completed at the service. The area manager told us internal quality teams checked these audits and identified trends and patterns across the provider’s other homes to see where further improvements were required. We found audits were completed and any actions from those audits were held on 1 overall action plan, making it easier to monitor and update.

However, we where we found some improvements in medicines management and accuracy of care records and planning, those improvements were either not checked or not known. The area manager said the provider’s policy was to check a percentage sample rather than all, meaning in some areas, it takes around 10 months before the provider got a complete picture of the areas they audited. The area manager reflected on this and had referred our findings to the provider to consider their processes for some audits.

Staff told us the registered manager and senior staff checked how they provided care to people. One staff member told us, “[Registered manager] always watches what we do and does spot checks.” The staff member told us the registered manager informed staff if their care practice needed to be change and did this in a supportive way.

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.

Staff were positive about the relationships developed with local GPs and other health and social care professionals.

The registered manager told us the chaplain was closely involved with end of life care and together they had developed an annual Memorial Service in November 2025 within the garden before continuing indoors. Families, both past and present, were invited to attend, contribute, and add personal memorials, creating a meaningful and inclusive act of remembrance that has been very well received. The registered manager told us, “This initiative has strengthened our connection with families and supports ongoing remembrance, reflection, and healing within the Cedar Lodge community.”

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.

Staff described how they demonstrated their own values of honesty when working with each other, so people would receive the care they wanted. One staff member said, “You have to be loyal [to your values] and tell other staff if they are doing something wrong.” This helped colleagues to develop their practice further and people’s care consistently improved. We have referred to examples in the report where the registered manager focussed on improving people’s quality of life, with a staff team that recognised people as individuals and adapting their approach to those they cared for to promote a positive culture to learn and improve.

The registered manager, area manager and clinical assessor took on board our feedback where we questioned some of the practices such as percentage audits and how they recorded certain checks. The area manager said they had taken learning from the inspection visit and had contacted the provider to share what we discussed and how certain areas could be improved upon. This demonstrated a positive approach to learning and improving.