Cedar Lodge Nursing Home

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• 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

Staff were clear about their responsibilities and roles and felt supported by the registered manager and the provider. The provider had clear governance systems which were used to monitor the quality and safety of people’s care. However, some management records were not streamlined enough to provide robust assurances around governance and reporting of events in the home and how Mental Capacity Act 2005 Code of Practice was considered when making decisions around people’s care. The registered manager updated the records during and straight after the site visit and took action to streamline the governance records. We did not find these improvement needs affected the safety and quality of people’s care and any future risks were minimised by the actions taken by the registered manager during this assessment.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had governance and management oversight systems in place. The management team completed a range of quality and safety checks and audits in the home and observed staff practice directly on a day-to-day basis. However, some management records were not streamlined enough to provide robust assurances on actions taken in relation to incidents, accidents and safeguarding concerns. For example, there was limited assurance on how the registered manager analysed those events, monitored correct external reporting and ensured required follow up actions were complete. Individual care records for some people lacked information on how mental capacity was assessed for those who lacked capacity to consent for use of bedrails and how decisions were made in people’s best interests for them to be safe. The management did not recognise when there was a lack of required records on how they considered the Mental Capacity Act 2005 to protect people’s rights. Management records, such as deprivation of liberty safeguards applications and authorisations matrix or resident’s list were out of date at the time of the site visit. The registered manager updated the records and provided assurances around management of incidents, accidents and safeguarding concerns during and following the site visit. However, we found these shortcomings did not impact on the safety and quality of people’s care. Ongoing risks were minimised by the follow-up actions taken by the registered manager.

Staff spoke positively about the leadership team, governance at the service and the hands-on approach of the registered manager. They told us the registered manager was very supportive and spent a large amount of the day with people and staff in the communal areas of the home. Staff members said, “We work very well together. The manager is very fair and transparent and supportive.”, “Staff meetings, supervisions, it all gets detailed what is expected of us and what our responsibilities are.”, “The manager makes sure everything is just right. I would go to her for anything, she is approachable and friendly; we are all comfortable with her.” and “Working here is like being at home, we are looked after and supported. We are supported if we have an emergency. We get along and any issues are resolved professionally.”

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.