The Cedars

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.

At times of staffing pressures, use of agency staff and gaps in oversight meant aspects of care delivery, documentation and routines did not always align with the service’s person‑centred values. Some people experienced reduced choice or engagement during busy periods, which contrasted with the stated cultural aims.

There was a positive and shared culture across the home. Staff consistently described the service as supportive and well-led, and people and relatives spoke positively about the values demonstrated in day‑to‑day care. One staff member told us the service was, “a friendly, warm environment where staff support each other.”

People and relatives experienced this culture through kind, compassionate interactions, with many describing feeling safe and well cared for. One person told us, “You couldn’t get kinder staff anywhere.” These comments reflected a shared understanding among staff of the importance of dignity, safety and treating people as individuals.

Management were visible and approachable, and staff felt confident to raise concerns and discuss any concerns. Staff we spoke with told us there was a clear expectation to escalate safety issues, reflect on incidents and learn from experience.

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 service was led by an approachable and compassionate registered manager, who was well known to people, relatives and staff. Relatives spoke positively about the registered manager, with many saying they would raise concerns directly with the manager if needed and felt confident these would be taken seriously. One relative told us, “If I had to complain, I would go to [Manager],” and another commented, “It all runs really well.”

Staff described leaders as supportive and inclusive, creating a culture where they felt safe to speak up, raise concerns and reflect on practice. One staff member told us the service was “a safe space where I can express myself without feeling judged,” and another said it was “a friendly, warm environment where we support each other.” Management promoted a culture of kindness, dignity and respect, which was reflected in the way staff spoke about people and delivered care.

The registered manager was visible and involved in day‑to‑day practice, with managers aware of people’s needs, risks and individual circumstances. Staff said management encouraged escalation of safety concerns and learning from incidents, and relatives gave examples where concerns or feedback had led to positive change.

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

Staff described a positive and open culture where they felt able to speak up about concerns, mistakes and wellbeing without fear of blame. Staff told us they were confident to raise safety concerns with managers and felt listened to and supported. One staff member told us, “Safety concerns are escalated to the manager and I feel able to do this.”

Staff told us, management were approachable and responsive. Supervision and informal discussions provided opportunities to reflect on practice, share concerns and identify learning. Staff felt concerns were taken seriously and actions were discussed openly, which supported transparency and trust within the team.

People and relatives reflected this openness, with most saying they would feel confident raising concerns with management if needed.

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 service promoted a respectful and inclusive culture, where staff described feeling valued and treated fairly. Staff feedback reflected an environment where people felt safe to be themselves, share views and raise concerns without fear of judgement.

The registered manager promoted equality and respect through day-to-day interactions, supervision and an open‑door approach. Teamwork and mutual respect were evident, and staff felt included in discussions about safety and care delivery.

The service supported people from diverse backgrounds and with differing needs. Staff adapted their communication and care approaches to meet individual circumstances, including sensory impairment, cognitive needs, faith and cultural preferences. This reflected a wider culture of inclusion that extended to both staff and people using the service.

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 not always effective in identifying and addressing issues consistently. Audits did not always capture gaps in medicines management, record‑keeping or care plan accuracy, and some review dates had lapsed. Oversight of staffing deployment, agency use, recruitment records and supervision required strengthening to ensure consistency and sustainability. Documentation following incidents, hospital transfers and changes in routine was not always sufficiently detailed to provide clear assurance.

Despite these concerns the provider had governance and management systems in place to oversee care quality, safety and performance, and these supported the delivery of mostly safe, caring and responsive care. Management were visible and accessible, and both staff and relatives expressed confidence in the management team. Relatives told us they knew who to contact and felt concerns would be listened to and acted upon.

Processes were in place to monitor quality and risk, including audits, reviews, meetings and external oversight from senior and operations managers. Health and safety checks and emergency planning documentation were in place, and managers demonstrated awareness of people’s needs, risks and priorities. Feedback from people and relatives had led to some positive service improvements, showing a willingness to learn and respond.

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 provider worked in partnership with families, health professionals and the wider community to support people’s wellbeing. Relatives told us they felt involved, informed and listened to, and many expressed trust in how the service worked alongside them.

People were supported to maintain community connections that were important to them. This included support to attend church services, visits from local faith leaders, family‑led outings, and engagement with community organisations. People’s spiritual needs were respected, and they told us they valued continued links with their faith and family. One relative said, “Being taken to church is very important to her.”

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 service demonstrated a willingness to learn and improve, supported by approachable management and staff who were reflective about practice. Staff told us they felt able to raise concerns, reflect on incidents and learn through supervision and training. One staff member said supervision and training “help me reflect and improve my practice.”

The registered manager encouraged learning from incidents, feedback and day‑to‑day experience, and there was evidence of change following concerns raised by people and relatives. Fire drills, safety reviews and discussions around health concerns were used to promote shared understanding and learning.

Staff meetings, flash meetings and informal discussions were used to share information about risks, changes in health and priorities for care. These supported learning in practice. However, meetings would have benefited from more consistent structure and documentation to ensure learning points, decisions and actions were clearly captured and followed up.