- Care home
Cedar Tree Care Home Limited
Assessment report published 2 December 2025
Contents
Ratings
Our view of the service
Date of assessment: 20 to 28 October 2025. This service is a care home providing personal and nursing care for older people, some who may be living with dementia, sensory impairment or physical disabilities. At the time of our inspection 38 people lived at Cedar Tree Care Home Limited.
The assessment was prompted in part by a notification of a safety incident when a person died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this assessment did not examine the circumstances of the incident. The assessment was also prompted in part by information of concern regarding the management culture created by leaders at the service.
However, the information shared with CQC about the incident indicated potential concerns about identifying and acting in response to deteriorations in health. This inspection examined those risks alongside how leaders shaped the culture of the service.
We found 4 breaches of the legal regulations in relation to consent, safe care, governance of the service and recruitment.
Care plans and risk assessments were not always accurate or updated following safety incidents. Records of people’s care were not always complete or accurate. When people needed the protections of the Mental Capacity Act 2005 to help protect their rights when making decisions, these had not always been recorded in line with this guidance.
The provider had not ensured all the required pre-employment checks had been completed on staff working in the home. Not all staff had completed training relevant to people’s care needs. Some staff felt communication could improve.
Cleaning records had not always been completed to show areas of the home and furniture had been cleaned as scheduled. We found some armchairs and areas of flooring were stained.
Medicines were not always stored in line with good practice.
Policies used by the service were not always up to date or reflected current good practice guidance. There was no evidence the provider's installation of a CCTV system had been planned in line with the guidelines set out by the Information Commissioners Office (ICO) who are the independent regulator for data protection and information rights.
Improvements were needed to show that complaints were responded to in good time and resolved with the involvement of people. It was not always clear how suggestions from people, relatives and staff were acted on to help improve the service.
Whilst staff felt supported by the registered manager, staff had mixed views on how the provider supported them. The provider had not always been considered as a leader who created an open and transparent culture, where staff felt confident to speak up.
There was a running schedule of on-going improvements to the care home environment however, it was not always clear how long items of equipment had been out of action for, and when certain maintenance jobs were due to be completed by.
Staff liaised with healthcare partners over any changes to people’s health and care needs. Leaders worked with other local authority and health partners to help achieve better outcomes for people.
We have asked the provider for an action plan in response to the concerns found at this assessment.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
People's experience of this service
People’s rights to have decisions made in their best interests, were not always upheld.
People were at risk of not always receiving consistent care and having their health outcomes monitored as planned as their care plans were not always accurate or up to date. Whilst some people and relatives had seen their care plans, others had not.
People had not always been involved in developments at the home. For example, the installation of a CCTV system and how this impacted on people’s feelings of privacy, dignity and trust.
People were supported by kind and caring staff who responded quickly to help people and understood people’s preferences. Staff understood people’s different communication needs and worked to ensure these were met and checked people consented to their care. Cultural and religious occasions were celebrated.
People enjoyed their meals, relatives felt welcome and people spoke highly of the activities they could take part in. They were supported to access other healthcare services and improve and maintain their independence and well-being.
The environment had built in safety features that helped to promote people’s safety, such as window restrictors. The environment was accessible to people who used a wheelchair or who had reduced mobility.