Cedarwood Lodge (Active Prospects)

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. At our last assessment we rated this key question good. At this assessment the rating has remained 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.

Accidents and incidents were recorded and reviewed to identify any actions that could be taken to prevent a recurrence. The manager explained how learning from incidents was identified and shared with staff, saying, “When there is an incident, we take it seriously. We organise a team meeting. We talk about anything that went wrong and what we can do to prevent it from happening again.”

We heard examples of action that had been taken where a need for improvement had been identified. Staff had been asked for their suggestions about how to reduce medicines errors. Staff suggested that rather than the shift leader take responsibility for administering medicines, as had been the case, another member of staff should perform this task and the shift leader should check they had done this correctly. The implementation of this suggestion had led to a significant reduction in the number of medicines errors.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was effectively managed and monitored. They made sure there was continuity of care, including when people moved between different services.

There were procedures in place to ensure people’s transition from other services was well-managed. Each person had a hospital passport, which contained important information about them to be shared with medical staff in the event of a hospital admission.

The provider worked with people to understand what being safe meant to them and the best way to achieve that. Staff focused on improving people’s lives while protecting their right to live in safety, free from abuse, discrimination, avoidable harm and neglect. The provider shared concerns appropriately when necessary.

Staff attended safeguarding training in their induction and had access to regular refresher training. Staff knew how to recognise potential abuse and understood their responsibilities to report any concerns they had. The provider had made information about safeguarding available to people in an accessible format.

Where people were subject to restrictions for their own safety, such as not being able to leave the home unaccompanied, the provider had applied for Deprivation of Liberty Safeguards (DoLS) authorisations. The Deprivation of Liberty Safeguards are designed to protect people who lack the mental capacity to consent to their care or treatment, especially when that involves restricting their freedoms.

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

We heard examples of how staff had worked together to identify measures which reduced risks to people where these had been identified. One person’s mobility had recently deteriorated, which placed them at an increased risk of falls. Staff met as a team to discuss how this risk could be mitigated and had implemented measures to reduce the risk.

Relatives and professionals were confident staff provided people’s care in a safe way. A professional told us the most recent annual reviews indicated, ‘That practice by staff was good and individuals supported safely.’

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

The home was safe, accessible and well-equipped. The provider had acquired the building in 2024 and had made significant improvements to the environment since then which had been beneficial for residents. These improvements included redecorating the home, replacing the flooring, improving the outside space, and installing a wet room and a new kitchen.

Staff carried out regular health and safety checks, including fire safety checks. A personal emergency evacuation plan (PEEP) had been developed for each person, which recorded the support they would need in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective induction, training and development. They worked together well to provide safe care that met people’s needs.

There were always enough staff on duty to meet people’s needs and keep them safe, including at night. Staff had access to management support when they needed it, including out of hours.

Staff received an induction when they started work and were required to achieve the Care Certificate to pass their probation. The Care Certificate is a nationally recognised set of core standards for staff in health and social care, ensuring they have the fundamental knowledge, skills, and behaviours to provide safe, high-quality care.

Staff had access to the ongoing training and support they needed to carry out their roles. This included mandatory and service-specific training, which was tailored to ensure staff had the knowledge and skills to understand and meet people’s needs. For example, staff told us they received training on the prevention of pressure injuries as one person had been identified as at risk of this. Staff received regular supervision, which provided opportunities to discuss their performance and development, and an annual appraisal.

Staff were recruited safely. The provider carried out pre-employment checks including obtaining a Disclosure and Barring Service certificate. Disclosure and Barring Service checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff assessed and managed the risk of infection. They controlled the risk of it spreading and understood their responsibility to share concerns with appropriate agencies if necessary.

Staff attended training in infection prevention and control (IPC) and understood how to protect people from the risk of infection. Staff had access to personal protective equipment (PPE) when they needed it.

The staff team carried out regular cleaning to ensure good standards of hygiene were maintained. We observed that all areas of the home were clean and hygienic during our visits.

Relatives and professionals confirmed the home was always clean when they visited. A relative told us, “The home is clean, it is neat and tidy.” A professional said of the home, “It is exceptionally clean.”

Staff made sure people’s medicines and treatments were managed safely and reviewed regularly. Staff knew and respected people’s preferences about their medicines.

Staff received training in medicines management and their competency was assessed before they were authorised to administer medicines. A member of staff told us, "The manager will do 3 observations and check your competency. There is a checklist they go through to make sure you are ready."

There were appropriate arrangements for the ordering, storage, administration and disposal of medicines. Staff carried out regular medicines checks and medicines were audited as part of the provider's quality monitoring processes.

The sample of medicines administration records we checked was accurate and up to date. Each person had a medicines profile which included guidance about the administration of any medicines prescribed ‘as and when required’ (PRN).

On our first visit to the home, we identified that one person had a medicine in stock which staff were not trained to administer. There had been no need to administer the medicine, but this presented a risk of delay in administration should it be required. The manager contacted the prescribing healthcare professional and arranged for the medicine to be provided in an alternative form which staff would be able to administer with the appropriate training, which the manager said would be provided.