The inspection took place 1 November 2016 and it was unannounced.

Yew Tree Holdings (Yew Tree Lodge) is a residential care home which accommodates up to 34 older people. On the day of our visit there were 26 people using the service.

There was a registered manager. 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 felt safe living at the service. It was evident from talking with staff that they were aware of what they considered to be abuse and how to report this. Staff knew how to use risk assessments to keep people safe, alongside supporting them to be as independent as possible. There were sufficient staff, with the correct skill mix, on duty to support people with their needs. Recruitment processes were robust. New staff had undertaken the providers induction programme and training to allow them to support people confidently. Medicines were stored, administered and handled safely.

Staff were knowledgeable about the needs of individual people they supported. People were supported to make choices around their care and daily lives. Staff had attended a variety of training to ensure they were able to provide care based on current practice when assisting people. Staff always gained consent before supporting people. There were policies and procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff knew how to use them to protect people who were unable to make decisions for themselves.

People were able to make choices about the food and drink they had, and staff gave support when required. Catering staff knew who required a special diet and this was taken into account. People had access to a variety of health care professionals if required to make sure they received on-going treatment and care.

People were treated with kindness and compassion by the staff, and spending time with them on activities of their choice. People and their relatives were involved in making decisions and planning their care, and their views were listened to and acted upon. Staff treated people with dignity and respect.

Care records were reflective of people's current needs and were reviewed and evaluated on a regular basis. People were supported to engage in a variety of activities, based upon their preferences. The service had a complaints procedure in place to ensure that people and their families were able to provide feedback about their care and to help the service make improvements where required.

People were complimentary about the registered manager and staff. It was obvious from our observations that staff, people who used the service and the registered manager had good relationships. We saw that effective quality monitoring systems were in place. A variety of audits were carried out and used to drive improvements.

The inspection team was made up of three inspectors. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with four people using the service, three of their relatives, four the staff supporting them and looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

There was an auditing system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, and concerns, thereby reducing the risk of harm to the people who lived at the home.

The service was clean and hygienic. We found examples of good practice regarding infection control and waste disposal. Maintenance issues identified at the last inspection had been attended to. For example, a new carpet had been laid in the main lounge.

Is the service effective?

People’s health and care needs were assessed with them and their relative/representative (where this was appropriate), areas of risk identified within the assessment had been documented and staff were given information in people’s care plans of how to minimise those risks Some of the care plans had still not been reviewed regularly, however we could see this had been addressed within the last two months.

Appropriate signage and adaptations had been made which enabled people to mobilise freely and safely around the home?

Visitors we spoke with confirmed that they were able to see people in private and that visiting times were flexible.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. Two people were able to tell us that they liked the home, and the staff who cared for them. We also had the opportunity to speak with three relatives during the day. They made comments such as, "The staff are kind and look after my Mum well”, the staff always have time for me, and I am kept informed when X is unwell” and “All the staff without exception are lovely to everyone, I watch them sometimes, they have so much patience with people, they really care”.

There had been relative/resident meeting since our last visit and suggestions were seen as a way that the staff could improve the service they provided.

Is the service responsive?

We looked at people's assessments of need, care and support. Care and support needs had been considered when formulating each person’s care plan. We found that new people admitted to the service had an assessment undertaken by a member of staff prior to admission. Risk assessments had been undertaken and systems had been put in place to minimise future risk. This meant that staff were fully informed about the person’s needs.

Is the service well-led?

The service had a quality assurance system, we saw records that showed that audits had been undertaken monthly to check that different aspects of the service provision had been undertaken in a timely manner. For example, there had been regular audits of the medication systems, cleaning schedules and incidents and accident forms. The service worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision.

The inspection team was made up of two inspectors. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

There was no auditing system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, and concerns. This increased the risk of harm to people and failed to ensure that lessons are learned from mistakes. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events that affected people’s safety.

The service was not wholly safe, clean and hygienic. We found examples of poor practice regarding infection control and waste disposal, and areas that needed further maintenance. This was putting people at risk of harm. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to infection control and the environment.

Is the service effective?

People’s health and care needs were assessed with them and their relative/representative, but not all areas identified within the assessment had been highlighted in people’s care plans. Specialist dietary needs were not always followed nor outcomes recorded appropriately. Some of the care plans had not been reviewed regularly. Care plans were therefore not able to support staff consistently to meet people’s needs.

People’s mobility and other needs were taken into account in relation to signage and building adaptation, enabling people to move around freely and safely.

Visitors we spoke with confirmed that they were able to see people in private and that visiting times were flexible.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing people’s needs and ensuring care and support needs are met consistently.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, “The staff are very kind to me, they help me although I do most things myself”. A relative said, “I visit my relative regularly and the staff have been very good to my mum, she has put on weight and is very happy”.

People using the service, their relatives, friends and other professionals involved with the service have not yet been asked to complete an annual satisfaction survey. There had been one relative/resident meeting since our last visit and suggestions were being looked into. Some people were starting to have their views and needs looked into, however not all peoples views were being sort.

We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in planning and reviewing their care.

Is the service responsive?

We looked at people's assessments of need, care and support. We found that not all of the identified care support needs had been considered when formulating a plan of care. We found that new people admitted to the service had not had an assessment undertaken by a member of staff at the home, and that the assessment undertaken by social services had been used. Assessments of risk to individuals were not always the subject of a full risk assessment with a management strategy for staff to minimise future risk. This meant that staff were not fully informed about the person’s needs.

We have asked the provider to tell us what improvements that will make in relation to co-operating with other services. There relationship with the district nurses who visit has improved, with staff assisting the nurses when appropriate.

Is the service well-led?

The service had a quality assurance system, records seen by us showed that not all audits had been undertaken monthly and therefore quality of the service was compromised. The service worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision. However internal reviews and checks were not always happening on a regular basis. The manager was fairly new to the service and evidence was seen that they had identified some shortfalls and were taking action to improve the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to improving the service provided.

At the last inspection Yew tree Lodge on the 18th, 29th and 30th of July we found that the provider had not taken steps to protect people’s safety and welfare. Staff had not always shown people living in the home respect or asked for consent before providing care. People were not receiving the medication they were prescribed. We observed instances of abuse which we reported to the social services safeguarding team. There were not sufficient, trained staff on duty to protect people or deliver their care agreed in their care plans. Care records were not up to date and changes had not been made when care needs had changed. There were no monitoring systems in place to make sure people received good quality care and there was a lack of effective leadership.

During this inspection on the 30th October 2013 we found staff at Yew Tree Lodge had worked hard to protect the people living in the home and make sure they provided the assistance needed to meet people’s agreed care needs.

We observed staff were protecting people’s dignity and showed respect in the way that they interacted with them. Staff asked people for their consent before providing care and support.

People living in home and their families had been involved in formulating the care plans. We found staff understood the people’s care needs and people were receiving their agreed care. A family member who we spoke with told us that they were pleased with the changes the home had made. They said, “Mum is much happier now and we see staff around and doing things with the residents, the atmosphere is much calmer.”

We found that people were receiving the medicines they were prescribed.

There were sufficient staff on duty who had received training and gained the skills they needed to care for the people at the home.

Monitoring systems were found to be in place to make sure people were receiving good quality care and that records remained up to date.

Two inspectors, undertook the inspection and they were joined by an Expert by Experience (people who have experience of using services and who can provide that perspective) part of the time. The inspection took place over ten and a half hours. We spoke with people living at the home and family members who were visiting that day to get their views about the quality of care provided. We also spoke with the manager, and other staff, we looked around the home, and viewed documents relating to staff and people living in the home.

People living in the service suffered from different forms of dementia, therefore communication was not possible with some people. Those who were able to respond told us that they liked the staff and found them to be friendly.

We found that care records did not fully detail the care and support that individual people required. None were signed to show consent to the care being given. The risk assessments did not fully explore all the risks of the individual.

The medication audit undertaken by one inspector highlighted serious problems.

The home has an ongoing plan for refurbishments and improvements. They had installed different baths to meet peoples’ changing needs.

There was no auditing being undertaken by the manager to ensure the safety and quality of the care provision. Records needed for the provision of care and support and health monitoring were not consistently accurate.

We made an unannounced visit to the service and spoke to people who use the service, some visitors, a visiting care manager, the home manager and to staff members. A CQC pharmacy inspector carried out a full audit of the medication systems.

People told us or expressed that they felt safe and well looked after. A visitor told us “I wanted (my relative) to be here. I came unannounced to have a look around and I was pleased with what I saw. I come and visit anytime I want and I telephone every day. The staff have been brilliant and very supportive”. Another visitor said “I have no concerns. I have never had a problem here”.

People said that the home was clean and that their bedrooms were kept clean. A visitor said “It‘s not the bees knees, it is not a hotel but it is homely and that’s why (my relative) fits in”.

People told us the food was good and that snacks were available in between meals. However people had to wait until breakfast, served after 8am, for a drink even though they may have risen at 6am. People told us that they would like to be offered a drink before breakfast.

People told us that there was not much to do as activities were limited and no one was employed to arrange activities. This meant that care staff arranged ad hoc activities when they could spare the time but nothing was planned or structured.

A visiting social care professional said they had no concerns about the service.

We talked briefly with sixteen people living in the home during our visit. They were in different areas of the home including the dining-room, the bar area and the lounge; and one person was in her own room. Most of the conversation was not meaningful, due to people’s dementia.

One person said: “It is lovely here the staff look after me very well”; and another said: “I am happy, happy."

We talked with a relative, who expressed his satisfaction with the standards of care, and his pleasure at his relative’s good progress.

We undertook an inspection of this service over three days to check compliance with the warning noticed and compliance actions issued following an inspection on the 9th May 2013.

The pharmacy inspector visited and found were still not receiving their medication safely or as prescribed.

Two inspectors visited the home they were joined by a specialist dementia advisor on the 29th July 2013. We found that the home remained non-compliant with all previous regulations, plus a further two regulations.

We had concerns for people’s safety as we witnessed four incidents during our visit which we passed on the local authority safeguarding team.

We found that people were not always being treated with respect and their privacy and dignity was not protected. People were not always given the opportunity to choose or consent to care.

People were not always receiving the care and support they needed or had been planned to ensure their health and welfare. Risk assessments seen had not been supported by robust instructions to staff to minimise the risks.

People could be a risk of dehydration and malnutrition as there was a failure to follow up identified low in take.

Many staff did not have the skills, knowledge and understanding to provide good quality care due to the lack of training and support.

The home lacked robust monitoring systems to ensure people received consistent good quality care.