Yewtree Care Limited t/a Yewtree Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to safe care and treatment and good governance.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always ensure a proactive learning or safety culture. Staff did not always identify or escalate concerns, and lessons were not always learned to improve practice. We saw a person had been placed at risk of harm due to an ill-fitting mattress. No actions had been taken by staff to address this concern which placed the person at further risk of harm. Staff actions demonstrated ineffective safety checks and inadequate learning processes.

Processes for reviewing accidents and incidents were not always effective in identifying causes, patterns or trends. Information was not consistently recorded across people’s records, increasing the risk that opportunities to learn and take action to prevent further occurrences could be delayed or missed. As a result, people could not be assured they would be supported in the safest and most appropriate way.

The provider did not always ensure continuity of care when people moved between services. Systems to manage and monitor people’s health and wellbeing were inconsistent. Advice from health and social care professionals was not always reflected in people’s care records, and care plans were not consistently developed to guide staff in managing specific health needs.

For example, a person did not have a care plan for a documented health need. Nurses were unaware the person had this condition, or how it affected them. This meant the person could not be assured of receiving effective pain management or support to improve their quality of life and movement.

This showed ineffective systems for sharing clinical information and increased the risk of inconsistent or unsafe care.

The provider supported people to understand what being safe meant to them and how to achieve that. People told us they were supported by staff who made them feel safe and relaxed. A person told us they felt “Very safe. There’s always someone around.” ‘Another person said, “I can relax. There are friends all around. It’s not noisy”.

Safeguarding training was undertaken by new staff during induction and there was a system to ensure staff undertook refresher training. Staff had an awareness of the signs indicating a person might be vulnerable to abuse and knew how to report their concerns.

The provider did not always work effectively with people to manage risks. Risk assessments and staff practice did not consistently ensure safe, person-centred care, and care plans did not always provide clear guidance. For example, a person’s care plan did not reflect clinical advice on recognising deterioration and complications of their health condition, or the actions staff should take. Risk management for pressure care was not always robust. People were observed sitting for long periods without suitable pressure-relieving equipment. A person’s mattress was incorrectly set for 90kg rather than their actual weight of 60kg. Incorrect mattress settings can increase people’s risk of developing tissue damage and pressure ulcers. Staff had not identified the error because the display box was under the bed. We raised this with the manager, and the mattress was replaced with one appropriate for the person’s weight.

Some risk management processes were effective, including the management of seizure-related risks. Care records clearly outlined how seizures presented, and the actions staff should take, including when to give rescue medicines and when to call an ambulance.

The provider did not always detect or manage environmental risks. For example, during a boiler breakdown, risks linked to transporting hot water from the kitchen urn to people’s bedrooms were not assessed, exposing people and staff to the potential risk of scalding. Some actions from a February 2024 West Sussex Fire Safety Inspection remained outstanding, increasing potential fire risks and potentially compromising safe evacuation. After our feedback, the provider arranged an external fire risk assessment, and we notified the West Sussex Fire Safety Inspection team.

There was evidence of regular safety checks for fire equipment, electrical and gas appliances, lifts and hoists. People had personal emergency evacuation plans (PEEPs) in place to support safe evacuation during emergencies.

In response to our feedback the provider was proactive in addressing the points we had raised. CQC were notified by West Sussex Fire Safety that following their visit to the care home on the 20 January 2026 there was a reasonable standard of fire safety, and the premises were not considered high risk.

The provider did not always ensure safe and effective staffing. Staff did not always demonstrate the knowledge or skills needed to deliver safe, consistent care. Staff practices and training records did not always demonstrate staff had completed or understood required learning.

The service supported 8 people with a learning disability. Staff were unable to demonstrate the required knowledge to support people with a learning disability and autistic people safely. The provider, and staff did not have an awareness of the Oliver McGowan code of practice. The code of practice is required by the Heath and Care Act 2022. It sets out standards of mandatory training requirements on learning disabilities and autism. The provider had failed to meet legal requirements including the requirement to ensure all staff had received training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.

Nursing staff demonstrated safe clinical practice. Safe employment processes protected people from the recruitment of unsuitable staff. There were enough staff to meet people’s needs in a timely way, and our observations reflected this.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Staff received training infection, prevention and control (IPC) but did not always apply their learning into practice. For example, in August 2025 the nursing home had a significant Covid-19 outbreak. Procedures observed by CQC inspectors at the time were not in line with national best practice guidance for minimising the spread of Covid-19 infections. In response to our feedback the provider took remedial action. At inspection there was a failure to ensure communal equipment used to deliver care was clean or hygienic and we informed the nurse in charge about this.

Staff wore personal protective equipment (PPE) to prevent the spread of infection. There were daily mattress checks to ensure mattresses were clean and well maintained. Cleaning schedules were in place. The home was clean and odour-free. Safe and hygienic processes were followed to minimise cross contamination from soiled laundry.

The provider made sure the management of medicines was safe. Medicines were stored in line with safety guidance including drugs to be stored securely. People received their medicines safely and in line with their preferences. There were systems in place that ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. People had regular medicine reviews with prescribers, to ensure their medicines were current and in line with the principles of STOMP (stopping over-medication of people with a learning disability or autistic people).

People consistently told us they had no concerns about their medicines. They told us they received medicines on time including pain relief. A person said, “It’s a fine art. I would think everyone in the home gets their medication at the same time.” Another person said, “They tell you if there are changes.”