The Cedars and Larches Care Home

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. This is the first assessment for this service registered under a new provider. This key question has been rated Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The provider's quality assurance systems and processes were effective. Staff and leaders had been provided with appropriate training to be effective in their roles. Systems kept people’s records confidential. There were mechanisms in place to allow people, relatives and staff to speak up and have their voices heard. There were policies and procedures in place to support workforce equality, diversity and inclusion. There was evidence of the provider liaising with health professionals to ensure safe care and treatment for people.

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.

The service 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. People, relatives and staff all felt listened to by the service. Everyone felt their views were valued and respected. Leaders had a clear vision about the type of care service they wanted people to receive. They aimed to share that vision with the staff team through meetings and in routine communication with the staff. They also role modelled their expectations by occasionally working care or nursing shifts themselves.

Leaders at all levels were visible within the service and they led by example. The service 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 benefited from having a strong leadership team and a staffing structure of a senior carer, or qualified nurse, in each of the two buildings on site. This meant staff benefited from having access to more senior and experienced colleagues should they need assistance.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Everyone felt able to openly speak up about anything that concerned them. Where feedback was sought, this was analysed for patterns or trends and enabled lessons to be learned and action taken to prevent recurrences. Staff members knew the relevant policies and procedures which directed their work including safeguarding and whistleblowing. There was training available, to enable staff to understand their duty of care to the people they cared for.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider had a diverse workforce, including people from overseas working in the care home. One staff shared how confident they were in the registered manager, for being open and honest, with weekly flash meetings for all heads of department, identifying where any changes needed to be made.

Responsibilities, roles, systems of accountability and good governance were in place. They were used to manage and deliver good quality, sustainable care, treatment and support. Effective governance systems assessed, monitored and mitigated the risks relating to the health, safety and welfare of service users. We found most of the quality audits were routinely carried out by the registered manager. We discussed the advantages of delegating some aspects of quality monitoring to others and sharing oversight. The provider had clear and effective management arrangements in place. For example, nursing staff were line managed by a clinical lead, which helped maintain quality nursing care. The registered manager had effective arrangements in place to ensure the necessary notifications, to the local authority and CQC, were submitted in a timely manner.

The service 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. External stakeholders, such as community health care agencies, told us the care home staff and leadership team were responsive, open and transparent, and that they adopted a collaborative approach. We saw evidence that the leadership team engaged with external community services to support links in the local community. For example, local religious organisations and charity groups.

The service focused on continuous learning, innovation and improvement across the organisation and local system. The leadership team had a good understanding of how to make improvements happen. For example, the registered manager had established an effective management structure and staffing levels which considered the challenges created by the care home consisting of two separate buildings. Lessons learned was shared across other parts of the organisation to ensure these were cascaded to help improve care. The service had developed a good relationship with external stakeholders, which included taking part in externally organised best practice initiatives, for example the Care Home Infection Prevention Control project and the Care Home access to Dentistry project.