The inspection took place on 6th October 2016 and was unannounced.

Tall Trees provides accommodation and personal care for up to 48 older people who may also have dementia and nursing needs. Care is provided on two floors. At the time of our visit there were 41 people living in the service.

The service had a registered manager in 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.

People were safe because staff supported them to understand how to keep safe and staff knew how to manage risk effectively. There were appropriate arrangements in place for medication to be stored and administered safely, and there were sufficient numbers of care staff with the correct skills and knowledge to safely meet people’s needs.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code of practice to supplement the main MCA code of practice. Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act.

People’s care plans were individual and contained information about people’s needs, likes and dislikes and their ability to make decisions.

People had access to healthcare professionals. A choice of food and drink was available that reflected their nutritional needs, and took into account their personal lifestyle preferences or health care needs.

Staff had good relationships with people who used the service and were attentive to their needs. People’s privacy and dignity was respected at all times.

People were encouraged to follow their interests and hobbies. They were supported to keep in contact with their family and friends.

There was a strong management team who encouraged an open culture and who led by example.

The management team had systems in place to monitor the quality and safety of the service provided, and to drive improvements where this was required.

The inspection took place on the 12 October 2015 and was unannounced. The service provides accommodation and nursing care for up to 48 people, providing accommodation over two floors. Most people had a diagnosis of dementia.

There was a registered manager in 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.

During this inspection we saw a mixed picture of care. The manager had been in post for about a year and was responsive and knew people’s needs well. Audits around the quality and effectiveness of the care being delivered were robust but did not always reflect the experiences of people living in the home. We also found that care records did not always reflect people’s needs accurately.

Staff were hard working but were unable to give people the care they needed in a timely way and care was not centred around the needs of individuals because staff had not received in-depth training on providing high quality dementia care. There were very few strategies recorded on how to pre-empt and understand people’s behaviours in order for staff to respond appropriately. Other training for staff was of a sufficiently high standard and there were systems in place to ensure staff got appropriate support. Recruitment and staff induction was robust.

Risks to people’s safety were reduced as far as possible but at times risks to people increased because they were not adequately supervised which was necessary due to some people’s behaviours and anxieties.

Staff knew what actions to take to promote people’s care and welfare and how to respond to any allegations of abuse, or identified concerns.

Staff were competent in giving medicines safely and had received appropriate training. People’s medicine records did not give specific instruction as to when staff should administer medicines when required to help reduce people’s anxiety or distress

Staff encouraged people to eat and drink enough for their needs and this was monitored. People were given appropriate dietary choices and staff monitored what people ate but records were not always sufficiently robust to show how people’s dietary risks were being managed.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider, manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager had a good understanding of the MCA and DOLS and was acting lawfully. Staff supported people appropriately to enable them to make decisions where they were able to do so. Consultation with people using the service and their families took place on a regular basis and there were a number of ways in which families were involved and consulted about the care needs of their family member.

People received good health care and access to relevant health care professionals but staff needed more guidance around providing better palliative care.

Relatives told us that staff were kind and attentive to their family members. We observed mostly positive practices and staff attending to people’s physical care needs but less so to their psychological needs. People’s dignity was preserved apart from one poor observation of practice which was referred to the manager to deal with.

Relatives told us they were involved and consulted about the standards of care within the home and their family members care. Some people using the service would be able to give their views and were encouraged to do so.

Activity hours were generous but we were unable to see how these were used effectively to ensure people received the appropriate amount of stimulation and activities centred around their needs, abilities and past interests.

The manager demonstrated strong leadership skills and was working hard to improve the service and consult with a range of people, their families and health care professionals in terms of how to improve the service.

Audits were robust however; we identified areas for improvement across the service particularly in terms of staff knowledge.

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

During our visit we saw that people were being treated with dignity and respect.

People we spoke with and visiting relatives told us that they were happy with the care provided. One visitor said, “I am very happy with the care my wife receives” and one person said that all the staff were very kind.

We saw that people experienced safe and effective care based on detailed care plans that encouraged independence. There were risk assessments that met individual needs and provided good guidance to staff to minimise potential risks. We saw a range of stimulating activities both within and outside the home to help promote independence and community involvement where possible.

People using the service were protected from abuse as they were supported by a staff team who had appropriate knowledge and training on safeguarding adults.

Staff we spoke with and records we reviewed, demonstrated that there were the appropriate number of staff on duty at the right times, to meet people’s needs. Staff were appropriately inducted and supported. They received ongoing training and guidance which provided them with the skills and knowledge to meet the changing needs of the people they were supporting

The provider had effective systems in place to monitor and assess the quality of the service. The provider regularly collected the views of families and there was good evidence that the provider was improving practice as a result of feedback and assessing quality.

We spoke with three people living in the service and two relatives. All expressed their satisfaction with the service provided. One person said, "It is always clean, we have never noticed any smells." Another person said "It is nice to get outside in the garden in the summer."

We saw that staff interacted with people who used the service in a respectful, caring and professional manner. Staff were attentive to the needs of people and responded to requests for assistance promptly.

We looked at the care records of six people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights.

Some of the people who use this service have difficulty understanding and responding to verbal communication. During our visit we were able to hold a verbal conversation with four people. Other people were able to make comments about specific issues, such as the activities that they enjoyed and the meals provided.

People with whom we spoke confirmed that they were generally respected and involved by staff wherever possible and were mainly positive about the care and attention provided by staff.

Visitors with whom we spoke told us that they were consulted with about the care that their relative were receiving and felt able to talk to staff. They confirmed that they were generally satisfied with the levels of care and welfare provided to their family member. They also told us that if they had any concerns about the care being provided they felt able to approach staff and were confident that these issues would be addressed.