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

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.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of the regulation in relation to good governance. Improvements were found at this inspection and the provider was no longer in breach of this regulation.

This service scored 75 (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 culture at Cedar Lodge was firmly based upon equity and inclusion. There was an acceptance of difference that was second nature to the management and staff group. One professional told us, “My colleagues, both in health and social care have expressed to me on many occasions, their satisfaction in the treatment, care and overall empathy with residents, that other homes would most likely find challenging.”

People and their relatives had opportunities to give their views and opinions during meetings with staff and management. They were kept up to date with the events within the service through newsletters. Relatives told us that they were kept up to date with changes in their family member’s needs.

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.

Since the last inspection, the registered manager had undertaken significant development in terms of oversight of the service. Since the previous inspection, an external consultant had been brought in to offer a wider perspective on the care market and to offer their expertise to managers. The stable management team were familiar and accessible to everyone at Cedar Lodge. Staff told us that leaders of Cedar Lodge were approachable and listened to feedback on many levels.

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

Staff told us that the registered manager and others within the management team where approachable and available to them. One staff member said, “They don’t hesitate, they take action straight away. They are well organised.” Staff had confidence that they would be listened to if they raised a concern.

People and relatives told us that the registered manager was approachable. Those who had raised concerns told us that there were systems to investigate issues and that matters raised did not prejudice them in the future.

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 described an inclusive culture, where they were treated fairly. A number described team working and how this was the strength of the service, giving examples of support given to them as individuals from team members and management alike. Regular staff meetings were held whereby all staff could contribute equally and were asked for their views on the service and how it could improve.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider’s quality assurance arrangements monitored the quality of care and people’s experience through its internal auditing processes. A wide range of audits were undertaken including checking infection control, health and safety and care plans. Data was used to identify trends and patterns in key areas such as accidents and incidents. This information was used to help the management team, drive improvement. Satisfaction surveys were also undertaken along with observations of practice. For example, there were routine reviews of people’s mealtime dining experience.

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 and managers told us about positive working relationships with health and social care professionals, we saw referrals has been made appropriately and professional advice was updated in people’s care records for staff to follow. Health and social care professionals gave positive feedback, and we saw that meetings and reviews had been held to discuss people’s needs and plan how best to meet them.

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.

The management team were able to demonstrate a desire to actively listen to all people involved in Cedar Lodge. The motivation was that of continuous learning from events. During our inspection a relative raised some concerns and these were promptly resolved with evidence produced showing action taken. Feedback from health and social care professionals was the service was continuously learning. One professional said, “Any concerns and feedback are always responded to. The service looks into each concern and provides a response which includes what they have already done or will do.”