Cedar Lodge

Risks to people were not always assessed, monitored or managed effectively, and lessons were not always learnt. Care plans and risk assessments lacked information to guide and inform staff about safe and effective care and were not always being followed by staff. This placed people at risk of harm.

People lived in a home where regular checks were completed to ensure the safety of the environment. However, actions identified during these checks were not always actioned in a timely way. During the assessment we identified concerns relating to fire safety that placed people at risk. We raised these concerns with the local fire service.The provider had a service action plan in place prior to our assessment, this identified areas of improvement to the environment. The provider told us the identified work had been scheduled for completion.

People’s rights under the Mental Capacity Act were not fully upheld and although people received their medicines as prescribed, improvement was needed with medicine records.

Staff did their best to support people and we observed caring interactions taking place between staff and people; however, feedback from people, families and staff highlighted shortfalls in staffing levels throughout the service.

We received mixed feedback from professionals about how well the home worked with external health and social care professionals to support positive outcomes. While some professionals identified areas where partnership working could be improved, others spoke positively about their experience of working with the home.

Governance arrangements were not effective and did not ensure risks were consistently identified or addressed. Leaders were approachable and staff spoke positively about working at the service; however, improvements were required to ensure that systems and processes were consistently effective in monitoring care and driving improvement. The provider and manager were responsive to feedback and took some immediate actions to address the safety concerns we raised during our assessment.

The provider was in breach of legal regulations relating to safe care and treatment, premises and equipment and good governance. We have asked the provider for an action plan in response to some of the concerns found at this assessment.

Staff promoted independence, choice, communication and meaningful activity. People and relatives were involved in decisions about their care and consistently reported that their family members had a good quality of life. Staff received training, and most staff felt supported and treated equally.