Cedar Tree Care Home Limited

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 service was in breach of 3 legal regulations in relation to people’s safe care and treatment, infection prevention and control, medicines; assessing people’s capacity and making best interest decisions; staff recruitment practices.

This service scored 41 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Concerns about safety were not always reviewed and lessons were not always learnt to continually identify and embed good practice.

Opportunities to reduce risks following safety events were not always identified. For example, care plans and risk assessments were not updated following safety incidents involving people whose behaviour could place themselves or others at risk.

The provider worked to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

People’s care needs were assessed prior to them moving into the service and this helped to ensure their care needs were known and could be planned for. Staff told us they would liaise with GPs regularly, for example, when there were changes to people’s medicines. People’s records showed they were visited by opticians and chiropodists to help maintain their health while living at Cedar Tree Care Home Limited.

The provider did not always work well with people and healthcare partners to fully understand people’s choices, what these meant to them and how to achieve decisions in people’s best interests. They did not always concentrate on improving people’s lives or protecting their rights.

When people had not been able to make decisions themselves about their care and treatment, these decisions had not always been recorded in line with the Mental Capacity Act 2005. The Mental Capacity Act 2005 helps to ensure people’s rights are upheld and they are given every chance to understand the information and weight up the different options and involve the views of any relevant medical professionals and others. We found this had not always been completed fully.

Whilst mental capacity assessments and best interest decision documents had been recorded for some decisions, these did not always provide sufficient information to demonstrate people had been supported to participate. For example, staff were asked to record all measures they had taken to support the person to make the decision, and this was often left blank or completed with ‘lacks capacity.’ Sometimes the decision identified as needed, was vague. For example, ‘Health needs to be maintained.’

Not all staff understood the Mental Capacity Act 20025 and records of staff training showed not all staff had been trained in this area.

However, staff had a better understanding of safeguarding and knew how to identify potential signs of abuse and how to report these concerns. Where people required restrictions to help promote their safety, these had followed the processes under the Deprivation of Liberty Safeguards (DoLS).

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and consistent.

We observed staff assisted a person to transfer where the person found it difficult to stand and records showed other staff had recently used another method to support them to transfer. Their care plan and risk assessments had not been consistently updated with this other transfer method or provided any guidance for staff on how they should make a judgement on the safest method to use. We found another person’s care plan and risk assessment were out of date and instructed staff to help the person stand for 5 to 10 minutes to relieve pressure however, this person was unable to bear weight and used a hoist for all transfers.

Care plans were not up to date and lacked consistent guidance on how people should be transferred, and so people were at risk of receiving inconsistent or unsafe care.

Staff completed records for when people expressed themselves in a way that could harm themselves or others. These often lacked sufficient description to understand what had fully occurred. We reviewed a record for an incident we observed and found this had not included all relevant details. Care plans and risk assessments did not include or provide guidance to staff on how to reduce risks and provide consistent and safe care when people could express themselves in ways that could cause harm to themselves or others.

When people needed care with pressure sores, care plans and associated records did not provide consistent guidance on dressing routines. Records did not show pressure sores were photographed, measured and evaluated at every dressing change to ensure an accurate and complete record of the pressure sores deterioration or healing.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Hoists were used to help some people transfer. One of the hoists was out of service and not being used. Whilst other hoists were available, staff told us that having a reduced number of hoists had negative impacts on how effectively they could work. The registered manager was unable to confirm how long the hoist had been out of service for however, a diary entry suggested it could have been from July 2025. This meant the service had been running for a significant period of time without an item of equipment needed to support the safe delivery of care.

The provider told us they had a running schedule of upgrades and improvements for the care home environment. New flooring and decoration had been completed in some parts of the home with further plans to roll this out throughout. Safety features such as window restrictors and underfloor heating which reduced the risks from hot surface radiators were in place. Items of large and heavy furniture were secured to walls to help reduce the risks of these toppling over.

The provider did not make sure all staff were suitably trained or that the necessary recruitment checks had been completed. They did not always make sure staff received effective support and development. They did not always support staff to work together well to provide safe care that met people’s individual needs.

The provider had not ensured all the required pre-employment checks to help inform their decision making when employing staff to work at Cedar Tree Care Home Limited had always been completed. This meant the provider could not demonstrate they had recruited staff in line with the requirements for people working in a care home. We asked the provider to take immediate action to ensure these checks were completed and they confirmed they would do so.

The provider had identified the areas of training staff needed to complete however, not all staff had completed this and their knowledge in some areas of care relevant to people’s needs was limited.

Staff told us they felt they supported each other well however, they felt communication could improve. For example, communication between the care staff and Nursing team. The registered manager told us the provider had recently made changes to the staff handover process and not all staff had been given the opportunity to attend a handover meeting. Handover meetings enable continuity of care as staff who are finishing their shift can pass on important information to the new members of staff starting their shift. This arrangement did not support staff to work together well to ensure people were provided with safe care.

Whilst we did not observe anyone waiting for staff to help them, some staff felt the afternoon shifts could feel pressurised. They reported the pressures of completing records impacted on their time available to spend providing care.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed areas of carpet and multiple armchairs were stained. The cleaning records for these areas as well as other areas and items of equipment, had multiple gaps where staff had not signed to say they had cleaned these areas as expected in line with the frequencies set out by the cleaning schedules. This did not provide assurances that the risk from infections was being detected, prevented and controlled. This placed people at increased risks from infection.

Shortly after our inspection the provider told us they would replace the carpets and armchairs.

We observed some staff with nail polish or acrylic nails. This was not in line with good infection prevention and control measures as it reduces the effectiveness of hand hygiene practices.

The provider did not make sure that the management of medicines and treatments was always safe and met people’s needs, capacities and preferences.

Prescribed skin creams were not stored securely. We found numerous prescribed creams in people’s bedrooms with no risk assessment in place to assess and mitigate any risks from potential access to them by others and stability at bedroom temperatures. We found a prescribed skin cream for one person, was in another person’s bedroom. This increased the risks of people using medicines that had not been prescribed for them.

Medicines administration records for prescribed skin creams did not record people had been offered their medicines as prescribed. There were multiple gaps in the records we reviewed, and staff had not used codes to confirm people had been offered their medicine and had declined this.

We found the management of other medicines to be in line with expected standards.