We carried out an unannounced comprehensive inspection of this service on 3, 4 and 14 October 2016. A breach of a legal requirement was found as we saw a prescribed medicine for one person had not been administered since the previous month. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirement in relation to the breach.

We undertook this focused inspection on 8 February 2017 to check that the provider had followed their plan and to confirm that they now met the legal requirement. This report only covers our findings in relation to the Safe domain. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Neem Tree Care Limited on our website at www.cqc.org.uk.

Neem Tree Care Limited is part of Sunflower Health Care which has four homes in the North of England and Neem Tree Care in London. The home has three units over three floors and two of the floors provided support exclusively to people from an Asian background. Neem Tree Care Limited provides nursing care and support for up to 57 older people, including people with dementia. At the time of our inspection there were 49 people living at the service.

The manager was a nurse who came into post on 2 January 2017. At the time of our inspection she had applied to the Care Quality Commission to become the service’s registered manager. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our focused inspection on 8 February 2017, we found that the provider had followed their plan of action, dated 3 January 2017, and that the legal requirement had been met. We have looked at all the Key Lines of Enquiry (KLOE) for Safe and because the provider is now compliant with all of these, we are changing the rating to Good for the Safe domain.

Medicines were administered and managed in a safe way.

Safe recruitment procedures were in place and since the last inspection the management structure had been reorganised, new staff had been recruited and there were enough staff on duty to meet people’s needs.

Systems were in place to safeguard people from the risk of abuse and staff knew how to respond if they suspected abuse.

Risk assessments were in place to minimise identified areas of risk. Systems and equipment were serviced and maintained to keep people safe.

The inspection took place on 3, 4 and 14 October 2016. The first day of the inspection was unannounced and we told the registered manager we would be returning the next day. The third day was also unannounced.

The last inspection took place on 29 May 2014 at which time the service was meeting the seven assessed standards.

Neem Tree Care Limited is part of Sunflower Health Care which has four homes in the North of England and Neem Tree Care in London. The home has three units over three floors and two of the floors provided support exclusively to people from an Asian background. Neem Tree Care Limited provides nursing care and support for up to 57 older people, including people with dementia. At the time of our inspection there were 49 people living at the service.

The registered manager was a nurse and had given in her notice prior to our inspection. After the inspection, the providers confirmed they had begun recruiting to the post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found one breach of the Regulations because medicines were not always managed safely.

We saw during the inspection visit there was not always enough staff available, but after the visit, the provider had begun to recruit a full staff team and restructured the management of the service.

The service had safeguarding and whistle blowing policies. Staff had attended safeguarding training and knew how to report safeguarding concerns. Risks to people’s safety and wellbeing had been assessed to keep people safe and staff knew how to record incidents and accidents. The provider followed safe recruitment procedures.

There were a number of regular maintenance and service checks carried out to ensure the environment was safe.

People were supported to have enough to eat and drink and were able to have food and drinks when they wanted to.

People had access to health care services and the service worked with other community based agencies such as a memory clinic.

People who used the service and their relatives told us staff were kind and their dignity and privacy was respected.

A complaints procedure was available and the provider responded appropriately.

The provider had systems to monitor the quality of service delivered and to ensure the needs of the people who used the service were being met. Information was analysed and used to improve service delivery.

All stakeholders indicated they could speak to the registered manager or providers who they felt listened to them.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

During our inspection we spoke with seven people who use the service and/or their representatives and a minimum of seven staff. People who use the service generally said that they enjoyed living at the home. They said the staff were caring and attentive to their needs. One person said “they are lovely and always smiling.” Other people commented that the staff were “good at knowing what I need.” People also said they were able to spend their time as they wished, on their own, or in the company of other people. However, all the people and their relatives that we spoke with said they would like more variety in activities provided by the service.

The staff conveyed a knowledge and understanding of each person's needs and how they liked to be supported. We saw the people who use the service and the staff had developed positive relationships with each other and there was good communication and a relaxed atmosphere within the home.

However, we identified that there were inadequate systems in place regarding consent and assessing people’s capacity to make decisions about their lives. This meant that the legal requirements relating to the obtaining of consent were not followed, which put people at risk of receiving or omission of treatment without their consent.

We also noted some shortfalls in relation to infection control and access to protective equipment, which could put people at risk from the spread of infection.

The staffing levels did not meet the needs of the people who use the service, and could put people at risk of inappropriate care. Similarly, the arrangements for the induction of new staff to the service were inadequate and put people at risk of being supported by staff who did not know their needs or how to support them appropriately.

We spoke with six people who use the service and relatives. People who use the service said their privacy and dignity was taken into account and relatives said they were kept informed about the care of their family member. People had their health and personal care needs assessed and have an up to date care plan.

One relative commented that the health and well being of their family member had noticeably improved during their stay at Neem Tree Care Centre. A comment was made that staff are “warm and caring”. One relative had raised a concern with the home about the care of their family member and this was being investigated.

Policies and procedures were in place for staff guidance on recognising and reporting abuse.

Induction training and mandatory training was in place for staff. All staff had received formal supervision with a manager. Staff annual appraisals had not been completed.

There was a system in place for obtaining the views of people who use the service and their relatives. Regular audits were carried out on the quality and safety of care.

On this occasion we did not speak to people using the service or their relatives. Our inspection focused on the management of medicines.

People said staff talked to them appropriately and showed respect to them. This was confirmed by relatives. We observed that staff asked people about their wishes and choices and gently encouraged people to follow directions, such as sitting at the dining table for lunch. People were then asked about their choices of meals.

Relatives reported that the home had arranged residents and relatives meetings and were pleased that they could give their views and make suggestions about the provision of the service. The minutes of a meeting held in December showed that it was well attended.

During our inspection, we observed that people looked well cared for and were appropriately dressed. This was confirmed by relatives. They said they were involved in the care planning process and the care reviews of people. Relatives told us staff supported people with their healthcare needs as necessary.

Relatives reported that people were engaged in recreational and social activities to keep them stimulated and active. We observed that people played games during the course of the day, one of which was linked to exercising the upper limbs of people by throwing rings. People appeared alert and well. We saw that they responded appropriately when staff talked to them.

We found that the provider had addressed all but one of the areas where the service had not previously complied with essential standards of quality and safety. Our findings showed that people were not always protected against the risks that can arise from the unsafe management of medicines.

Neem Tree Care Limited was first registered in April 2011 and this report contains the findings of the first review of compliance with essential standards. At the time of the visit there were 12 people using the service. We received some feedback from relatives and staff but few people using the service were able to give us feedback because of the nature of their needs.

Relatives praised the quality of the premises and one said that “the home is very nice and clean”. Another said that the home is close and easily accessible and they could therefore visit the home easily. They reported that staff always made them feel welcome to the home.

Relatives said that they were involved in discussing the care of people when people first moved in the home, but had not been further involved in reviewing people’s care to decide whether their needs were being met.

We were informed by relatives that people were offered choices about the meals they wanted to have and that people received enough food during mealtimes. Relatives added that people received fresh fruits in the home. This was confirmed by staff.

Relatives told us that overall people received a good standard of personal hygiene and that staff monitored people’s health and welfare and took action to inform the doctor when necessary. They said that on some occasions, people were not appropriately stimulated and involved in recreational and social activities, because some staff were not sure how to stimulate people. They were satisfied with the attitudes of staff although they thought that some staff were not adequately trained to care and support people with dementia care needs.

Relatives informed us that they had not had an opportunity to complete a satisfaction survey about the quality of the service but said that the management of the home was approachable and would discuss their concerns if they thought that this was necessary.

We spoke with ten people using the service, six relatives, two visitors of people using the service and sixteen staff. The staff included the manager, operations director, finance director, two nurses, one cook, one maintenance person and nine care staff.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

Staff had a good understanding of the Mental Capacity Act 2005 which meant people received the appropriate support to be able to make their own decisions, or where required decisions involving appropriate people were made in the best interests of the person.

Staff were trained and responsive to any signs of abuse and avoidable harm. People reported that they felt safe and well cared for. Any risks to people were assessed and reviewed regularly to ensure people's individual needs were being met safely.

Staffing levels had been increased since the last inspection and levels were under review weekly so that people’s needs could be met appropriately.

The home was clean and arrangements were in place to control and prevent infection.

Is the service effective?

New staff underwent induction training and all staff had opportunities to attend training so that they could care and support people effectively.

Staff valued people’s diverse needs and were able to communicate with people in their preferred language so that people had a good understanding of their care and treatment and were able to make informed decisions.

People had access to healthcare professionals to meet their needs and the service worked well with other healthcare professionals to coordinate people’s care.

Is the service caring?

During our inspection, we observed staff were caring and people were treated with dignity and respect. People told us they were happy, well cared for and treated with respect.

People were involved in their care and care plans provided staff with guidance on how to meet people’s needs.

Comments we received included “there are always loving people around you”, “some of the carers are very caring and very good, sometimes they can have an off day, just like me and you” and “it is like a family here”.

Is the service responsive?

People where possible were involved in making decisions about their care. People were supported to attend activities within the service and in the community.

Relatives told us they were always kept up to date with the condition of their family member. People were enabled to maintain relationships with their friends and relatives.

Is the service well-led?

The provider and manager actively sought the views of people and their representatives so that areas for improvements could be identified and addressed.

All the staff we spoke with said they were supported to carry out their role and were provided with support and training. They told us they were able to raise any concerns they had with the manager and provider.

The provider had in place systems to monitor the quality of the service and where shortfalls were identified action plans with timescales were drawn up to address them.