Cedar Oak Healthcare Services Ltd

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 changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safe and effective staffing, safeguarding and ensuring suitable staff were employed.

This service scored 38 (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 did not promote a proactive or positive culture of safety based on openness and honesty. Concerns about safety were not consistently listened to, investigated or reported, and lessons were not learned to improve practice. This meant risks to people were not recognised, monitored or mitigated.

Accidents and incidents were not always clearly reported by staff to ensure action was taken and people’s needs monitored. The provider completed a monthly accident and incident analysis and spreadsheet. However, a review of people’s records identified a number of concerns which had not been reported as incidents. These included a person who had experienced two falls resulting in them having to wait for long periods for medical attention and a second person who had bruising which was not reviewed. In addition, we reviewed care records and spoke with 2 relatives regarding the levels of distressed behaviour shown by their family members towards staff. There was no system in place to monitor these incidents and no guidance for staff regarding how to support the person during these times of distress. This placed people and the staff supporting them at risk.

Where incidents had been reported, records did not clearly show how concerns were investigated, what action was taken, or how improvements were monitored. The provider was unable to demonstrate that appropriate action had been taken or how learning had been used to prevent recurrence.

The provider did not work effectively with people or partner organisations to ensure safe systems of care. They did not consistently assess, monitor or manage risks to people’s safety, and continuity of care was not always maintained, including during transitions between services. This meant people were at risk of receiving unsafe care at the point of discharge. Systems for transitions between services were not always safe. Although the provider told us that people’s needs were assessed prior to their support starting, we found that for some people the assessment took place after they had been discharged from the hospital. This meant their care was based on potentially outdated information. For example, urgent equipment was requested for one person after their return home when it became clear their needs had changed. This meant people were at risk of receiving unsafe care as appropriate equipment was not in place.

The provider obtained peoples medical histories from their GP; however, this information was not consistently used to inform care planning. Guidance relating to people’s specific health conditions was not always available to staff, meaning staff were not always aware of the support required, what signs of deterioration to monitor or what action to take to maintain people’s health.

Where healthcare professionals had provided advice to manage risks, there was limited evidence that this had been implemented. For example, repositioning guidance to reduce the risk of skin breakdown had not been incorporated into care plans or risk assessments. This demonstrated a failure to implement and monitor guidance to ensure people received safe and consistent care.

The provider did not work effectively with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. This demonstrated a failure to recognise safeguarding concerns and take appropriate action.

Prior to our assessment, we were notified of a concern by an external agency, which should have prompted a safeguarding referral being submitted by the provider. Following further review, both prior to and during our assessment, we found further concerns which the provider had failed to ensure were reported to the local authority safeguarding team. This meant the local authority was not aware of significant concerns relating to both staff and people using the service. Issues included police involvement, unexplained bruising, staff sleeping whilst in duty and a report of medicines going missing. We found some of these concerns had been reviewed internally, although the action taken was not always appropriate and/or clearly recorded. The failure to share this information in a timely and transparent way meant the local authority could not ensure appropriate action had been taken in response to concerns and was therefore unable to monitor people’s safety effectively.

The provider did not work effectively with people to understand and manage risks. People did not always receive safe, supportive care that met their needs or enabled them to do what mattered to them. This meant staff did not have access to essential risk information at the point of care.

Risks to people’s safety were not always assessed in a timely and comprehensive way. We identified a number of people using the service had no risk management plans on the electronic system used by staff. This included people with complex health care needs, some of whom required the support of 2 care staff to support them. The registered manager told us risk assessments had been completed but had not been inputted onto the electronic system. This was a concern as none of the people we visited had copies of their care plans or risk assessments in their home. This meant staff did not have access to this important safety information when providing people’s care.

Where risk assessments had been completed we found these to be exceptionally complex, using clinical descriptions regarding the support people needed and were too lengthy for staff to read and digest making it difficult for staff to identify and prioritise key risks and deliver safe care.

In addition, where people’s needs had changed, risk assessments had not always been updated which meant staff did not have access to current information. For example, one person had a risk assessment in relation to moving and handling which was 45 pages long and had not been adapted as their needs had changed. This increased the risk of unsafe or inappropriate care.

Following our assessment the provider forwarded evidence to show risk assessments had been completed and a process of monitoring and review implemented. These processes will require time to be embedded into practice.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Risk in people’s homes were not routinely assessed to ensure they were safe and that staff could deliver care in a suitable environment. These included risks relating to mobility within the home, use of stairs and equipment such as stair lifts, access to kitchen facilities, fire safety arrangements and security considerations.

We did not find information available to guide staff in responding to emergencies, such as how to isolate water and electricity supplies. This meant risks in people’s home environments were not consistently identified or managed, increasing the risk of avoidable harm.Following the assessment the provider forwarded information to demonstrate these concerns were being addressed.

For some people we found consideration had been given to their living environment and appropriate equipment was available to support staff in providing people’s care safely.

The provider did not ensure staff were deployed effectively to meet people’s care needs. People did not consistently receive care at the times they required, and staff did not always receive effective training, supervision or support to deliver safe care. This placed people at risk of unmet needs, particularly where care was required for continence support and meal preparation

A review of call times in April 2026 showed that over 14% of people’s care calls were over 45 minutes late and over 12% of calls were over 45 minutes early. This meant people were unable to rely on the time staff would arrive to enable them to plan their routines. Where staff arrived early for care calls this meant there were short gaps between visits despite the majority of these being to support people with continence care and meal preparation. This also left a longer gap between the last visit of the day and the first call the following day. The provider told us they always ensured travel time was planned between visits. However, we found this was not the case with all care calls. There was a clear correlation between calls with no travels time planned and staff arriving late.

We received mixed views in relation to people’s call times. Comments included, “We have times which vary by half an hour to an hour, so it is hard to say if they are late. Occasionally they go over that but they don’t always call”, “They are very good. We have a window of when they can turn up which we agreed at the beginning. They are spot on” and, “We aren’t told what time to expect them so I can’t say if they’re late. It would be useful to know when they’re going to come.”

Whilst staff received training in their roles, this was not always completed in an effective way. Staff completed a range of 45 training courses. A cross section of staff records showed staff were regularly completing between 10 and 17 training courses in a single day with some staff completing all 45 training courses over a 5-day period. These courses included important information such as safeguarding, moving and handling, risk management and information relating to specific health conditions. This increased the risk staff could not apply their learning in practice putting people at risk of not receiving appropriate care. The provider told us they provided additional face to face training in key areas such as moving and handling and first aid to ensure staff were competent in these areas. In addition, no induction checklist had been completed for 3 of the 4 staff members’ files we reviewed. The registered manager acknowledged this concern and told us they would ensure additional checks of these systems would be implemented going forward.

Greater oversight of recruitment information was required. We identified some staff had gaps in their employment history which had not been discussed with them, and interview questions were not comprehensively completed. We found 2 staff members had identical interview forms in place, neither of which had a name to show who it referred to. This demonstrated insufficient oversight of recruitment processes to ensure staff were suitable for their roles.

In other areas we found the required recruitment information was in place. These included references being sought from previous employment, proof of the right to work in the UK and Disclosure and Barring Service checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. This demonstrated insufficient oversight of recruitment processes to ensure staff were suitable for their roles.

Following our assessment the provider forwarded evidence they were addressing concerns relating to how people’s care visits were planned and their care monitored.

Systems were in place to support staff to follow infection prevention and control practices. staff understood how to apply this in practice when supporting people

People and relatives confirmed that staff consistently wore personal protective equipment when supporting them. One person told us, “They have the proper plastic aprons, gloves and uniforms. If there is anything going round, they will wear masks. They will wear the masks all the time if I ask them.”

Staff told us they had access to personal protective equipment such as gloves and aprons. They told us they had received training in infection prevention and control which they felt had been useful in their role.

The provider did not always ensure medicines were managed safely or in a way that met people’s needs, capacities and preferences.”

Where people were prescribed as and when required medicines (PRN) medicines there were no protocols in place to guide staff on when or how these should be administered. This meant there was a risk people may not receive medicines appropriately or that staff could not demonstrate safe decision-making.

When PRN medicines had been administered, staff did not record the dose taken. Where the medicines were prescribed for pain relief, records did not highlight if the person had been offered their medicines or how their level of pain was assessed. For those people who were supported with the administration of pain patches, there was no record of where the patch was placed or if the patch was still in situ when the person was next supported, which increased the risk of incorrect application or duplicated dosing.

Following our assessment the provider sent evidence to show they were taking steps to address these concerns.

In other instances, we found records showed people were supported with their medicines safely. Staff had received training in medicines administration, and their competency had been assessed. Relatives told us staff supported their family members well with their medicines, including the application of prescribed creams to help ensure their skin remained healthy.