Cedar Court Nursing Home (Dementia Unit)

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 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.

Staff consistently told us how everyone worked together to ensure people received holistic support. The management team knew people well and were compassionate and caring about people, their relatives and the staff team. We observed the management team to be visible and involved in the support people received.

The provider 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 registered manager had the relevant experience and qualifications to manage the service. Staff were complementary about the management team and confirmed they were approachable, visible and available to support the staff team when needed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

We observed the management team promoting an open-door approach during our visit, we found staff at ease to come to the managers with queries. Staff confirmed they felt confident to speak up and would be listened to if they raised concerns.

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 clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At the last assessment the provider was in breach of Regulation 17 HSCA RA Regulations 2014 Good governance. At this visit the effectiveness of audits in identifying where improvements were needed had improved. This demonstrated ongoing monitoring was used to continuously improve the practices at the home. The registered manager showed us the systems in place to ensure all aspects of the service was regularly audited and had an ongoing action plan to drive improvements. This meant the provider was no longer in breach of this regulation.

Staff understood their role and responsibilities. The management team monitored and reviewed the actions, behaviours, and performance of staff. We saw when required appropriate action was taken to address staff performance.

The provider 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.

People’s holistic needs were met as external professionals worked with the staff team to ensure people’s changing needs were met. Safe practices were in place and followed to ensure people accessed external professional services as needed. The registered manager confirmed they worked in partnership with visiting professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

When areas for improvements were identified, actions were taken to address them. For example, a medicines audit, identified that some ‘as required’ (PRN) medicines were out of date or missing. We saw that this had been addressed at the time of the audit.