Cedar Tree Care Home Limited

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of a legal regulation in relation to governance at the service.

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Not all staff and relatives felt the provider ‘led by example’ to create an open and transparent culture and engage people, relatives and staff in the shared direction and culture at the home. For example, recent minutes of the relatives meeting stated not all people and relatives knew who the provider was when they were in the home. We discussed this with the provider who stated they explained to people they were the maintenance person rather than the provider as they were often completing maintenance jobs. Relatives and staff provided other examples of where they did not feel consulted with and involved in the shared direction of the home, for example, there had been no consultation or involvement of people, relatives or staff in the installation of the CCTV system.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Staff mostly described the registered manager as kind, approachable, compassionate and ‘hands-on.’ Staff spoke positively about the registered manager listening to their concerns, stepping in to help cover any staff absences and their encouragement of good practice and staff development. However, the feedback on the provider’s leadership style was mixed with some staff reporting the provider could have a negative impact on their well-being. Several staff reported that communication and consultation on important developments needed to improve, for example on the installation of CCTV system, the scheduling of the on-going maintenance work and the development of electronic records.

People did not always feel they could speak up and that their voice would be heard.

Not all staff understood ‘whistle-blowing.’ Whistle-blowing is a law that protects staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care. Not all staff felt there was an open culture in the organisation to enable them to speak up and raise concerns freely or that their views would be considered.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had identified equality and diversity training for staff to complete however, the training matrix showed a significant number of staff had not completed this. Not all staff felt treated fairly by the provider.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Policies in use at the home, had been reviewed recently however, these reviews had not identified they were out of date and the guidance they referred to had been replaced with new guidance. Audits had not identified gaps in cleaning schedules and had not identified areas of flooring and armchairs were stained. Nor had they identified people’s care plans, risk assessments or records were not always accurate. Audits on staff training had not checked compliance against all areas of required staff training. Medicines audits had not identified topical medicines were not stored securely or risk assessed for access by others and temperature stability, nor had they secured improvements to ensure codes were used to explain when medicines were not required or refused. It was not always clear how long items had been broken for. For example, a hoist was out of action and from records we viewed it would appear this had been out of action for a significant length of time. A cupboard with resources for activities for people to use had a broken lock and there was no clear plan of when this would be replaced meaning people had a reduced choice of activity resources available. Systems and processes designed to assess, monitor and improve the quality and safety of services and reduce risks were not operated effectively. Following our assessment the provider sent us an action plan that set out timescales for some maintenance work and the replacements of flooring and armchairs.

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.

Leaders worked in partnership with a range of agencies, such as the local authority and health partners. Information was shared appropriately with them to help achieve better outcomes for people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Opportunities to learn lessons were not always taken. It was not always clear how suggestions from relatives completing feedback surveys had been acted upon to help improve the service. Action plans had not been in place to help identify what was needed to help maintain quality within the service. For example, there were multiple gaps in staff training records and no effective plan on how compliance with the required training would be achieved.