Cedar House

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 requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider was in breach of legal regulation in relation to people’s safe care and treatment, medicines management and premises and equipment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were procedures in place for handling and learning from incidents and complaints, but there was not always a proactive approach to continually learning from these to improve practices. Staff recorded incidents and the registered manager reviewed these to make sure they were responded to and to identify any actions to reduce the risk of re-occurrence. However, we were not assured the registered manager consistently reviewed this information strategically to identify any trends or patterns in the incident reporting. This meant they did not always use the information to identify further learning and improvement opportunities for service improvements. The registered manager understood and explained their duty of candour responsibilities when things did not go right. They told us, “If something goes wrong you need to say sorry and make sure staff learn from it and it doesn’t repeat itself.” Staff and relatives were able to raise issues and some relatives said they thought there was nothing to improve at the service. Professionals told us the managers raised issues about people’s care to them in good time.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The registered manager completed an assessment of people’s needs to establish if the service could meet their needs before they moved to the home. People and their family were able to visit the home first. We saw that when people wanted to move out, the service supported them to work with other statutory agencies, such as the local authority, to make this happen. Staff worked with other services to review and support people’s care needs, such as community centres.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff supported people to live in safety, free from bullying, harassment, abuse, discrimination and neglect. The provider shared concerns quickly and appropriately. Staff and the registered manager knew how to raise concerns, including using whistleblowing processes. The managers promoted awareness of safeguarding regularly. Staff felt supported to report issues. Restrictive practices, such as the use of raised sides when people were in bed, were legally justified, proportionate, necessary and in line with the Mental Capacity Act 2005. The provider undertook unannounced checks of the service to check on how staff were supporting people. For example, the registered manager had visited the service overnight.

The provider did not always work well with people to understand and manage risks to their safety and wellbeing. This meant people’s care did not always meet their needs in a way that was safe, supportive and enabled people to do the things that mattered to them. We found serious concerns regarding the safe management of the risks from choking for some people that the provider had not identified. We alerted the provider so they could take urgent action to address these concerns during our assessment. People’s care and risk management plans did not always set out how risks to people’s health and wellbeing were assessed and the actions staff needed to take to support them. For example, one person’s plans did not consider how some of their health conditions may affect them or provide guidance for staff to recognise the signs of the person was becoming unwell due to those conditions. Also, the plans for some people who lived with epilepsy were not clear on how differing arrangements to monitor them in the event of a seizure during the day or at night had been assessed to ensure these were safe and suitable. However, staff knew people well and relatives felt people were safe and did not raise any concerns about the management of risk in the service. A relative told us, “[Their family member] is definitely safe there.” Risk management plans identified other risks to people and measures to reduce these. These included areas such as known allergies, supporting with skin or pressure area care, using wheelchairs, oral health and accessing transport.

The provider did not always detect and control potential risks in the care environment or make sure equipment and facilities always supported the delivery of safe care. The home environment was suitable to meet people's needs, but some areas were not appropriately maintained and were in need of cleaning, repair and redecoration. For example, we found a used continence aid left in the sensory room and a dried substance stuck to a person’s bed pillow case on their bed. The surface of a padded bedside bumper used to keep a person safe was worn and cracked in numerous places from long-term use and needed to be replaced due to infection control risks. A device used to suction a person’s excess saliva to mitigate the risk of choking had a used tube and no sterile tube stored with it. The device’s battery did not hold any charge meaning it had to be plugged in and could not be brought to the person if they needed it, but records stated this was checked on a daily basis as safe to use which was not accurate. We saw contractors on site making improvements and repairs to the environment when we visited unannounced in January 2025. Other areas of the home, such as the main kitchen and communal areas including the lounges were very clean, well maintained and safe to use. Relatives liked the home environment and the accessible garden. One told us, “The layout of the place is suited to [their family member].” There was enough room for people to use wheelchairs or other mobility equipment to move around safely. This equipment appeared in good order and staff checked regularly that it was safe to use. There were fire safety arrangements in place.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. We received mixed feedback about the staffing levels. Relatives felt there were enough staff but some staff thought there needed to be more of them on shift to be able to meet people’s needs in a timely manner and spend meaningful time with them. We saw that while there were enough staff on duty to keep people safe, at times people were left unoccupied and waiting for staff to spend engaging and meaningful time with them. The registered manager said they did not use a tool or an assessment based on people’s needs to determine the levels of staffing required to always meet people’s needs appropriately. Relatives and professionals’ feedback about staff was positive. Relatives appreciated the staff team was consistent so people could develop relationships of trust with the staff who supported them. A relative commented, “Other homes have changes of staff but at Cedar House you get to know them well.” Staff received an induction, training and regular supervision to support them in their roles. They completed training in a variety of areas, including learning disability and autism awareness. Staff said they found training helpful. The provider had appropriate recruitment processes in place so they only recruited suitable staff.

The provider assessed risks of infection and had processes in place to prevent and control these, but these were not always implemented effectively. Whilst some communal areas and bedrooms were clean, others were not. We saw dirt in some toilet and en-suite bathrooms and around the flooring in one kitchen area. The flooring join between a person’s bedroom and their en-suite bathroom was ripped and dirty. The service’s cleaning schedules and infection and prevention audits had not identified and enabled the provider to take action to address these issues. People’s relatives and professionals told us they found the home clean when they visited. Laundry facilities were maintained appropriately.

Staff supported people to receive their medicines as prescribed, but the provider did not always ensure medicines were managed in line with its procedures. Staff demonstrated a good understanding of people’s medicines support needs and had completed training on how to administer medicines. However, the provider had not always ensured this training and staff competency assessments were completed in accordance with their own policies and procedures. For example, this had not been completed in line with procedures for some special administration techniques, such as administering emergency seizure recovery medicine or through a person’s feeding tube. The service did not always monitor the medicines fridge temperature correctly to ensure medicines were stored in suitable conditions. People’s care plans set out the support they needed to take their medicines, including ‘when required’ medicines such as paracetamol. Staff maintained administration records to note when they supported people to take their medicines. The medicines room and medicines support equipment were kept clean and in good order. Relatives were happy with people’s medicines support. A relative said, “They do all [the person’s] medicines, we’re happy with that. We trust them.”