Two Trees Caring Home

About the service

Two Trees Caring Home ‘hereafter; referred to as Two Trees is a residential care home that provides personal care and support for up to twenty-eight people with a learning disability, autism or who have complex needs associated with their mental health. At the time of the inspection there were twenty-six people living at the service.

People’s experience of using this service and what we found

Right Support:

People were not always supported to have maximum choice and control of their lives and staff were not always supporting people in the least restrictive way possible. The service could not always demonstrate they were acting in people’s best interests.

Managers and staff were committed to supporting people in line with their preferences. People had fulfilling lives and staff supported people by focussing on their strengths and encouraging people to be as independent as possible. However we found more work was needed to ensure people were protected from the risk of harm as systems and process did not always provide staff with all the information needed to meet people's needs safely.

Right Care:

Risks such as those associated with people's complex health and / or medical needs had been assessed. However, staff did not always have access to all the information they needed to meet people’s needs safely, due to technical issues with the electronic care planning which were continuous and ongoing.

Staff respected the people they supported and provided care that was caring and compassionate. People were encouraged to take positive risks to enhance their wellbeing and support plans reflected their individual needs and preferences.

Right Culture:

The ethos, values and attitudes of staff helped to ensure people using the service were enabled to lead confident, inclusive, and empowered lives. Staff understood their role in making sure that people were always put first, and their care and support was tailored to their individual needs and preferences. The management team had created an open and transparent culture, where constructive feedback was encouraged.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published on 28 June 2018)

Why we inspected

We received concerns that potentially indicated a closed culture where concerns relating people health care needs were not being appropriately shared with families or escalated to medically professionals. As a result, we undertook a focused inspection to review the key questions of safe, effective, and well-led only.

You can see what action we have asked the provider to take at the end of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Two Trees Caring Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, need for consent, deprivation of liberty safeguards (DoLS) and good governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Two Trees Caring Home provides care and accommodation for up to 28 people with learning disabilities. On the day of our inspection there were 23 people living at the care home. In relation to Registering the Right Support we found this service was doing all the right things, ensuring choice and maximum control. Registering the Right Support (RRS) sets out CQC’s policy registration, variations to registration and inspecting services supporting people with a learning disability and/or autism.

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.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated good:

People were not all able to fully verbalise their views and staff used other methods of communication, for example pictures or visual choices. We met and spoke with 21 people during our visit and observed the interaction between them and the staff.

People remained safe at the service. People were protected from abuse as staff understood what action they needed to take if they suspected anyone was being abused, mistreated or neglected. Staff were recruited safely and checks carried out with the disclosure and barring service (DBS) ensured they were suitable to work with vulnerable adults. There were adequate numbers of staff to meet people’s needs and help to keep them safe.

People’s risks were assessed, monitored and managed by staff to help ensure they remained safe. Staff assessed and understood risks associated with people’s care and lifestyle. Risks were managed effectively to keep people safe whilst maintaining people’s rights and independence.

People had their medicines managed safely, and received their medicines in a way they chose and preferred. Staff undertook regular training and competency checks to test their knowledge and to help ensure their skills in relation to medicines were up to date and in line with best practice.

People were supported by staff who had received training to meet their needs effectively. Staff meetings, one to one supervision of staff practice, and appraisals of performance were undertaken. Staff completed the Care Certificate (a nationally recognised training course for staff new to care). Staff confirmed the Care Certificate training looked at and discussed the Equality and Diversity and the Human Right needs of people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People's health was monitored by the staff and they had access to a variety of healthcare professionals. The registered manager worked closely with external health and social care professionals, to help ensure a coordinate approach to people’s care. Some people’s end of life wishes were documented and included information on people’s wishes when needed.

People’s care and support was based on legislation and best practice guidelines; helping to ensure the best outcomes for people. People’s legal rights were up held and consent to care was sought as much as possible. Care records were person centred and held full details on how people liked their needs to be met; taking into account people’s preferences and wishes. Overall, people’s individual equality and diversity preferences were known and respected. Information recorded included people’s previous medical and social history and people’s cultural, religious and spiritual needs.

People were treated with kindness and compassion by the staff who valued them. Staff had built strong relationships with people who lived there. Staff respected people’s privacy. People, or their representatives, were involved in decisions about the care and support people received.

The service remained responsive to people's individual needs and provided personalised care and support. People’s communication needs were known by staff. Staff had received training in how to support people with different communication needs. The provider had taken account of the Accessible Information Standard (AIS). The AIS is a requirement to help ensure people with a disability or sensory loss are given information they can understand, and the communication support they need.

Staff adapted their communication methods dependent upon people’s needs, for example using simple questions. Information for people with cognitive difficulties and information about the service was available in an easy read version for those people who needed it.

People were able to make choices about their day to day lives. The provider had a complaints policy in place and it was available in an easy read version. Staff knew people well and used this to gauge how people were feeling.

The service continued to be well led. People lived in a service where the provider’s values and vision were embedded into the service, staff and culture. Staff told us the registered manager and management team were very approachable and made themselves available. The provider had monitoring systems which enabled them to identify good practices and areas of improvement.

People lived in a service which had been designed and adapted to meet their needs. The service was monitored by the provider to help ensure its ongoing quality and safety. The provider’s governance framework, helped monitor the management and leadership of the service, as well as the ongoing quality and safety of the care people were receiving.

As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Two Trees Caring Home our website at www.cqc.org.uk.

Two Trees Caring Home is registered to provide accommodation with personal care, for up to 28 people who have a learning disability and may also have physical disabilities.

On the day of the inspection there were 21 people living at the service.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. The registered manager is also the registered provider. 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.

Throughout the inspection there was a calm, friendly and homely atmosphere. People appeared relaxed and happy. We were supported throughout the inspection by two members of the management team.

We met and spoke with 16 people during our visit. People were not all able to fully verbalise their views and used other methods of communication, for example pictures and sign language. We therefore spent time observing people. One person when asked if they were happy at Two Trees said; “I like living here.” One staff member said; “It’s a lovely place to work in.”

People’s medicines were managed safely. Where errors had been found, action had been taken to reduce the risk of recurrence.

People’s individual risks were documented, monitored and managed well to ensure they remained safe. People had their continence needs managed and assessed by a continence nurse specialist.

People were supported to maintain safe health care through regular access to health and social care professionals, such as district nurses.

People’s needs were met by sufficient numbers of staff. People who required it had additional staffing. People were observed to have additional support at meal times with some people receiving one to one support. Rotas recorded sufficient staffing to meet these requirements. Staff were knowledgeable about people's needs and received training, for example manual handling training, to help keep people safe.

People's dietary needs were recorded and staff were aware of how to meet these needs safely. For example people whose health had deteriorated were encouraged to eat what they wanted and when they wanted and advice was taken from healthcare professionals. People who required them had food and fluid charts completed.

People’s care records held information about how people wished to be supported and what level of support was required to help keep them safe. Records were regularly updated to reflect people’s support needs; particularly for people who required increasing support due to the deterioration in their health. For example some people liked to get up really early and staff assisted people to help keep them comfortable and safe. While other people either liked to stay in their rooms or went to their rooms to rest due to their deteriorating health where staff visited them regularly.

Two Trees Caring Home provides care and accommodation for up to 28 people. On the day of the inspection 22 people lived within the home. Two Trees Caring Home provides care for people who have a learning disability and may also have physical disabilities.

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.

On the day of our inspection there was a very calm, friendly and homely atmosphere. People were relaxed and happy. People’s relatives all spoke highly about the care and support Two Trees Caring Home provided. A relative comment read, ‘A friendly atmosphere where people are cared for in a very professional and personal manner’.

People and their loved ones were full of praise about the caring nature of the staff. Comments included, “My sister is met by care and compassion. Staff are like guardian angels”, “I feel blessed that the staff care so much. I see so much positive interaction” and “Staff are very caring and very patient. They go out of their way to help”.

Staff encouraged people to be independent and promoted people’s freedom. People moved freely around the building and its grounds as they chose.

Care records were comprehensive and written to a good standard. They contained detailed personalised information about how individuals wished to be supported. People’s individual method of communication was taken into account and respected. People’s risks were well managed, monitored and regularly reviewed to help keep people safe. People had choice and control over their lives and were supported to take part in a varied range of activities both inside the home and outside in the community. Activities were meaningful and reflected people’s interests and hobbies.

People had their medicines managed safely. People were supported to maintain good health through regular access to health and social care professionals, such as district nurses, behavioural advisors and speech and language therapists.

Staff put people at the heart of their work; they exhibited a kind and compassionate attitude towards people. Strong relationships had been developed and practice was person focused and not task led. Staff respected people’s individual needs around their privacy and dignity.

The service had an open door policy, relatives and friends were always welcomed and people were supported to maintain relationships with those who mattered to them. Staff were well supported through induction and on-going training. Staff were motivated and encouraged to enhance their skills. Individual development was promoted. A staff member said, ““I’m always being encouraged to progress and further my knowledge.”

People were supported by staff who had a strong understanding of how to keep them safe. Advice was sought to help safeguard people and respect their human rights. All staff had undertaken training on safeguarding adults from abuse, they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated. The manager had sought and acted on advice where they thought people’s freedom was being restricted.

Staff described the management as very supportive and approachable. Staff talked positively about their jobs. Comments included, “My jobs lovely, it’s not a chore, it’s very rewarding”, “I love my job, some days can be stressful, but when you get to make their day better, that’s enough for me”, “I get praised, a thank you as I go out the door, goes a long way” and “I hate it when I’m not here. The residents make my day, they make me laugh, I couldn’t do anything else. Just making peoples’ lives better, going above and beyond makes such a difference. Everyone should have the opportunity to have an excellent life and the residents here do.”

People’s relatives and health and social care professional’s opinions were sought and there were effective quality assurance systems in place that monitored people’s satisfaction with the service. Timely audits were carried out and investigations following incidents and accidents were used to help make improvements and ensure positive progress was made in the delivery of care and support provided by the service.

At this inspection because we only looked at people's financial records, and some elements of their care records, we were unable to answer all of 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. If you wish to see the evidence supporting our summary please read the full report.

From the information we looked at we were able to make a judgement that Two Trees Caring Home was safe.

At our inspection of 13 October 2013 we found there was not an effective system in place to support people to manage their money, to ensure people were protected from the risk of financial abuse. When we checked three people's money we found there were discrepancies between cash held by the home and the recorded balance for all three individuals. The provider had not sufficiently recorded why they held people's money and who acted as appointee for individual people's finances, where they did not have the capacity to manage their finances.

At this inspection we checked if improvements had been made to the systems the provider had in place to support people to manage their money. We found the system for holding and recording people's monies had been changed and was more robust. When we checked the monies held by the home against the financial records for four people we found these to be correct.

We looked at the care plans for the same four people and found a section detailing their financial needs had been added. This section recorded the individual's mental capacity to manage all, or some elements of their finances, the name of the appointee who acted on their behalf and what money they received. We found, in all the care plans we looked at, that this information had been added and was correct for each individual.

This meant that people who used the service were protected from the risk of financial abuse, because the provider had put effective systems in place to support them to manage their finances.

Everyone we spoke with was happy living in the home. The comments we received included 'It is nice here'the food is lovely and the staff are nice,' 'It is lovely, I am happy here'I can do what I like'I go shopping and I like to do my washing.' From observation of care we concluded people were all looked after well the staff worked professionally with people, and the team were well organised.

We judged there were satisfactory systems in place to protect people from the risk of abuse. However due to the complexity of the system to manage people's finances we could not be assured there was not a risk of abuse and / or financial mismanagement of people's finances.

The accommodation was well furnished, decorated and maintained. The home was very clean and there were no offensive odours.

On the day of the inspection there were satisfactory staff on duty. There was a suitable recruitment process in place to ensure people employed were deemed as suitable people to work with vulnerable people. Training provision was overall satisfactory.

The service had an adequate quality assurance system. Record systems regarding care planning, staff recruitment and training, and the general management of the home were satisfactory, although improvement was required to records regarding people's finances.

We spoke with or met all 27 people who used the service, eight staff members and three visiting professionals. As some were unable to communicate with us we observed staff interaction with them. We also spoke with the registered manager.

We looked at the care records of six people who used services and considered aspects of their care and treatment.

Not all the files we looked at identified all the people's needs and not all were completed accurately. This may mean that staff did not have the information they needed and people's care needs may not be met.

One relative survey returned to the home said, 'I am very pleased with everything at Two Trees'. One professional survey from a local G.P. said, 'A well run caring home which feels like a large extended family'. One person who used services said, 'Staff helps me'.

Some people felt at risk from other people in the home due to people either shouting at them or being aggressive.