This inspection took place on 8 January 2019 and was unannounced. The inspection continued on 10 January 2019 and was announced.

TreeTops is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

TreeTops is registered to provide accommodation and residential care for up to 18 people. At the time of our inspection there were seven people living at the home, some of whom were living with a diagnosis of dementia. The home is set out over three floors. Access to the first floor is by stairs or chair lift. The ground floor provides access to a secure garden area. The third floor was not in use at the time of our inspection.

This inspection was brought forward because concerns had been expressed about the safety of people living at the service. We shared those concerns with the local authority and the fire service.

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.

Quality monitoring and audits had not been completed which meant areas of the service being provided were not meeting the requirements of the regulations. There was a lack of consistent and effective management and leadership, which coupled with ineffective quality assurance systems meant issues were not identified or resolved.

There was inadequate information about people's risk of falls as records relating to this did not contain sufficient detail. Where people were at risk of falls staff tried to encourage them to remain seated unless supported by staff. Risk assessments for people's individual care needs were not accurate and lacked detail. Systems in place did not always consider the least restrictive options, which put people at risk of losing their independence and freedom of movement.

Serious incidents had not been reported to the appropriate authorities. Accidents and incidents were not fully documented and followed up on continuing risk.

Managing risk in regard to the safety of the home was not robust. Fire safety checks such as weekly alarm testing had not taken place since October 2017, and new staff had not received fire training. Following our inspection, we made an immediate referral to the Fire safety team who have since visited the service. Essential checks on the safety of water temperatures were not in place, this meant there was a risk of legionella.

People did not always receive their medicines safely by staff who had been trained to administer them. Staff were not always clear about their responsibilities and role in relation to medicines. People were not encouraged to remain independent in the management of their medicines. Lessons were not always learnt or shared with staff when errors occurred. When health care professionals had given the provider specific instructions on how to care and support people, these were not consistently followed putting people at risk of unsafe or inappropriate care

Policies and procedures in relation to infection control and fire were not up to date or being monitored by the provider. Measures to prevent and reduce the risk of infection control had not always been taken. Staff did not always wear Personal Protective Equipment [PPE] such as gloves and aprons when supporting people with personal care or dealing with soiled laundry. Staff were unable to explain how to ensure people remained safe from infection spreading within the home. Staff had not received infection control training, or their training they had previously received was out of date.

Systems, processes and practices did not keep people safe

This unannounced inspection took place on 28 September 2017.

Treetops Residential Care Home is registered to provide accommodation and personal care for up to 18 people in a residential area of Lyme Regis. At the time of our inspection there were 11 older people living in the home.

There was a registered manager in post at the time of our inspection. 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, staff, relatives, professionals and the providers described that the home had been through a challenging period. We found evidence of this in some records not having been updated and formal audits not undertaken or recorded. However, people were happy with their care and they shared appreciation and confidence in the registered manager, owner and staff team.

Staff were consistent in their knowledge of people’s care needs and spoke confidently about the support people needed to meet these needs. They told us they felt supported in their roles and had taken training that provided them with the necessary knowledge and skills. There was a plan in place to ensure staff received refresher training as deemed necessary by the provider.

People felt safe. They were protected from harm because staff understood the risks people faced and how to reduce these risks. They also knew how to identify and respond to abuse.

People told us they received the care and support they needed. They also told us they saw health care professionals when necessary and were supported to maintain their health by staff. People’s needs related to on going healthcare and health emergencies were met and recorded. People received their medicines as they were prescribed.

Everyone described the food as good and there were systems in place to ensure people had enough to eat and drink.

People had support and care when they needed it from staff who had been safely recruited.

People were engaged with activities that reflected their preferences, including individual and group activities both in the home and the local area.

Staff understood how people consented to the care they provided and encouraged people to make decisions about their lives. Care plans reflected that care was being delivered within the framework of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards had been applied for when necessary.

People were positive about the care they received from the home and told us the staff were kind. Staff were cheerful and treated people and visitors with respect and kindness throughout our inspection.

At our last comprehensive inspection on the 30 September 2016 we found that the provider was failing to comply with Regulation 17 Good governance, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We were concerned that people’s care records and individual risk assessments had not been kept up to date, and the systems to monitor this were not effective. The systems to record when people had been supported to receive prescribed creams were not being consistently used, the systems to monitor medicines administration were not effective and that accident and incident records had not been completed with all relevant information.

As a result we issued a warning notice telling the provider that they must improve the governance at the home by date. The provider wrote to us and told us what they were doing to address this warning notice. At this focused inspection we looked at the actions taken and checked that the provider was now meeting this regulation.

We undertook this focussed inspection to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the “all reports” link for Tree tops on our website at www.cqc.org.uk.

The inspection visit took place on 10 March 2017. Tree Tops is home to up to 18 people in a residential area of Lyme Regis. At the time of our inspection there were 13 people living in the home.

The service had a registered manager at the time of our inspection. 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.

At this inspection we found that there had been improvements with regard to the reviewing of people’s individual care records. Five of the six records we looked at had been fully reviewed and risk assessments had been assessed. One person’s records evidenced that staff and the provider were working to develop the plan of support for the person and were requesting outside professional help. As such the risk assessment and care plan had yet to be updated meaning there was still work to do to fully comply with the regulation.

Medicine administration records had improved and concerns over the recording of support given by staff with regards to the administration of creams had largely been addressed. However we found that one of the five records we looked at for the preceding two weeks prior to inspection had four entries missing. We noted that there was a system of audit but as this had not been carried out during the last two weeks this had not yet been picked up, the provider agreed to address this without delay. We further noted that the storage of medicines did not comply to appropriate guidelines and further work was needed to ensure the safe storage of medicines. We have made a recommendation about this..

We looked at the recording of accidents and incidents at the home which had caused concern at the previous inspection. We found that when people had a recorded accident in their care records there was also a corresponding report in the accident / incident book.

The inspection took place on 30 September 2016 and was unannounced. At the last comprehensive inspection on 9 September 2013 we found a breach of regulations. The service did not have an effective system to undertake audits of people’s care documentation, accidents within the home or cleaning schedules to ensure all information held was current and completed accurately. A follow up inspection on 10 October 2013 found the service was now meeting essential standards of quality and safety.

Treetops is a residential care home located in Lyme Regis that is registered to accommodate a maximum of 18 older people who may be living with dementia or a sensory impairment. At the time of the inspection there were 13 people living there.

The two providers were very involved in the day to day running of the home. One of the providers was also the ‘registered manager’ for the service. 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.

There was insufficient evidence to show that quality assurance systems were being maintained, or were effective in identifying risks and areas for improvement. This included audits relating to accidents and incidents, and medicines. A new care planning system had been recommended following a care plan audit; however its implementation was incomplete. This had not been identified by the provider’s quality assurance systems. This meant action had not been taken to review people’s risks and care plans to ensure information was complete and up to date, and their needs could be met safely.

The service did not notify the Care Quality Commission of all significant events which had occurred, in line with their legal responsibilities.

The service was not always safe because risks to people’s safety were not always fully assessed, recorded and reviewed, and staff were not consistently following safe practice around recording when giving people their topical medicines.

Staff had not had individual supervision for six months, and some staff told us they did not feel well supported. New staff had shadowed senior staff, but had not had any supervision or training, although they felt well supported by the staff team. They had not had the opportunity to read people’s care plans before supporting them, but had a good knowledge of their needs which they had gained from working with other staff.

Several members of staff had left over recent months, some of whom had responsibility for introducing a new care planning system following recommendations by an external auditor. The task had not been properly completed which meant there was inconsistency in the quality and accuracy of care plans and guidance for staff in how to meet people’s needs. Despite this, staff had a good knowledge of people’s individual support needs and provided good quality care. This was confirmed by people and their relatives. One person told us, “It’s perfect here…it’s lovely, there is no problem with the care”.

Staffing levels had been reduced because staff had left, however the registered manager assured us current staffing levels were safe. They were themselves ‘working on the rota’ pending the recruitment of new staff. They told us the home was not fully occupied, with 13 people living there rather than the 18 people they were registered for. During the inspection we observed staff presence in the communal areas was frequent, with staff responding to people’s individual needs as required. People told us staff responded quickly to their requests for support.

The providers aimed to protect people from the risk of abuse through the provision of policies, procedures, safe recruitment and staff training. At the time of the inspection a safeguarding process was

Our inspection of 9 April 2013 found that although the provider had some systems to monitor the quality of service people received, the provider did not have appropriate systems to identify, assess and manage certain risks in the home. The home did not undertake audits of people’s care documentation, accidents and incidents, or have cleaning schedules to monitor the cleanliness of the home.

During this inspection, we found that the home had an appropriate system to audit people’s care records. We found that accidents and incidents within the home were monitored that reduced the risk of reoccurrence and that cleaning schedules had been implemented.

We spoke with five people and one person’s relative. All spoke positively about the home, the level of care they received and the staff employed to provide their care. One person told us, “The staff are really kind – nothing is too much bother”, while another said “I’m happy here.”

People told us that care was delivered to meet their needs. People were protected from harm as there were appropriate safeguarding procedures and staff told us they felt supported by the provider through appropriate training.

The home had some suitable systems to monitor the quality of service provided. However, the absence of checking care plan documentation, accident analysis and infection control measures had not ensured that some documentation was correct or had been accurately completed.

Our inspection of 23 October 2012 found that two people did not have care records that showed their individual care needs and treatment. The home had no records showing the individual weight for seven of the nine people using the service. We saw a medical document had been incorrectly filed, which may put people at risk of receiving care against their wishes or other people not receiving appropriate care. We served a warning notice which required compliance with the standard by 26 November 2012.

During this inspection, we found that the home had now completed care records for these two people, every person within the home now had a record of their weight and all medical documentation was appropriately filed in the care plan of the person to whom it related.

However, we found that people were not always involved in making choices or were able to express their preferences. The provider had not always completed an assessment of people’s needs to ensure people received individual care and treatment.

Staff had not completed training to ensure people were protected from the risk of abuse and had not received recent relevant training in key areas.

The provider had undertaken some quality assurance checks, but audits relating to the quality of service provision and risk areas for people in the home had not been completed.

We found that care records were not completed appropriate and some records were absent.