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 requires improvement. At this assessment the rating has remained 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.

This service scored 54 (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 was working towards creating a shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The provider had now met with relatives to introduce themselves and share information on developments at the service. This included assurances that any further development of CCTV in the service would be completed in line with current guidance however, the registered manager told us any developments in the CCTV systems were currently on hold. These meetings helped to ensure relatives’ views were heard directly by the provider and could be used to shape and develop the service. A further meeting had been arranged. The provider had started to work towards ensuring relatives’ views were included in the development of the service however, this way of working still needed time to fully embed.

Further work was required to help ensure the provider’s shared direction and culture at the service fully supported staff to feel their voices were included, valued and respected.

Leaders were working towards understanding the context in which the provider delivered care, treatment and support. They were working towards developing the culture and values of their workforce and organisation.

At this inspection we continued to receive positive feedback regarding the registered manager. For example, one relative told us, “I just can’t praise the registered manager enough, they always have time for everyone.” However, feedback regarding the provider continued to be mixed, while some feedback was positive, some continued to raise concerns that the provider had not yet been successful in creating a trusting, open and blame free culture. Actions, such as meeting with relatives and undertaking staff stress risk assessments, took some steps to attempting to understand what issues in the culture of the organisation needed to be addressed. However, there had been no further actions identified as a result of the staff stress risk assessments to address some of the issues raised, for example, bullying. Work to improve the culture of the organisation was still not yet fully embedded.

The provider had not yet developed and embedded a positive culture where people felt they could speak up and their voice would be heard.

Staff had now all completed training in ‘Whistleblowing’. Whistleblowing is a law that protects staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care. Staff we spoke with were knowledgeable on who they could speak to if they had any concerns for people’s safety at the service. However, further work was needed to develop the culture of the service to ensure there was full confidence in how whistleblowing operated.

The provider worked to support diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff had now all completed training in equality, diversity and inclusion. However, further work was needed to develop the culture of the service to ensure staff views were listened to, valued and included in the development of the service. For example, actions were needed to address areas of concern highlighted in the staff stress risk assessments.

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

Policies had now been reviewed and updated however, the provider’s complaints policy remained inaccurate and the provider’s policy for ‘challenging behaviour, violence and aggression’ was focussed on how restraints could be used rather than on person-centred dementia care and how to understand people’s behaviours.

Audits were now more accurate however, further improvements could still be made. For example, audits had not identified which care plans had been audited and so there was no system to show audits would systematically audit all care plans over a period of time.

There was an action plan in place to show the work that had been planned to improve and update the service. However, this had not always been followed or updated. For example, the provider had identified they would replace the chairs at the service as they were visibly soiled at our last inspection. The chairs remained visibly soiled at this inspection and had not been replaced. There was no update to the action plan to explain why this had not been followed.The registered manager told us that following the inspection the chairs had been professionally cleaned.

The standard of record keeping had improved since out last inspection.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider had started to meet with relatives to listen to their views and to communicate updates on maintenance projects and any actions taken on relatives’ feedback. This helped to demonstrate improvements were being made to the service and communicated to relatives. However, more work was required to fully embed this way of working.

Further work was required to ensure audits robustly tested levels of compliance and identified and addressed shortfalls. For example, whilst some improvements had been made, we still found some shortfalls with mental capacity assessments, best interest decision making, some care plans and risk assessments and records.