Archived: TreeTops Residential Care Home

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 from harm. The service did not always provide staff that had the right mix of skills, competence or experience to support people to stay safe. Staff had not completed induction training, or had not been kept up to date with training the service deemed essential.

Staff had not had individual supervision or had their competencies assessed. New staff informed us 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.

People were not safeguarded against the risk of being cared for by staff that were unsuitable to work in a care home. The staff recruitment files evidenced, and staff informed us, they started work before suitable checks had taken place such as the Disclosure and Barring Service (DBS), which includes criminal records checks. Files did not contain reference checks or previous employment histories.

People were not involved in day to day decisions about their care and treatment and staff lacked knowledge about the importance and guidance around making a decision in a person's best interest. Where people were deprived of their liberty, records relating to this had not been completed in line with the Mental Capacity Act 2005 (MCA). Deprivation of Liberty Safeguards (DoLS) authorisations were out of date and had not been reapplied for. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the MCA.

People's care plans and associated records did not detail their most current care needs and some documents had not been reviewed. Where records had been reviewed, this process was not thorough and did not identify any changes. People’s preferences and choices for their end of life care were not recorded, the registered manager told us they had not considered people’s end of life wishes.

We have made a recommendation regarding involving people in end of life discussions.

The service took cultural, ethical and religious needs into consideration. People told us they had opportunities to follow their faith. People’s relatives and friends could visit the home whenever they choose. They told us staff were kind and caring. There was a complaints process in place and people and their relatives told us they would speak with the registered manager if they had any concerns.

People told us they enjoyed the food and were able to make choices in regard their meals. One person told us they liked to eat later in the day, and staff respected this wish. Where people had allergies or specific nutritional needs the staff and chef were aware.

People’s information was stored confidentially in locked areas of the home. Daily charts and basic information about people was kept in the staff office and completed by staff at intervals throughout the day.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

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.

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 underway, and the providers were working with other agencies to investigate and determine what action was needed to keep people safe.

Staff knew how to make sure people’s legal rights were being protected when they did not have capacity to make specific decisions for themselves. The service had involved people’s legal representatives to make sure any decisions were made in the person’s best interests. Care plans contained clear guidance for staff to promote people’s ability to make decisions. Applications had been made for people to be cared for under the Deprivation of Liberty Safeguards where appropriate.

People were supported to maintain good health and had access to healthcare services. People were referred appropriately and guidance followed. One health professional commented, “My team visits often. I’ve not heard anything untoward. We are contacted appropriately and when I’ve been here I’ve found things very good”.

People had sufficient to eat and drink and received a balanced diet according to their needs and wishes. People were extremely positive about the quality of the food. Comments included, “They always ask me what I want for my lunch”, “The food, considering the situation, is excellent, I do really enjoy it.”

There was an activities organiser employed by the home and a weekly activities programme that people could participate in if they wished.

We saw that staff promoted people’s independence and treated people with dignity and respect. This was confirmed by a relative who told us, “I have never seen anyone be treated with anything other than respect, I’ve only ever seen, politeness, respect and dignity”. People’s relatives said they were made welcome and encouraged to visit the home as often as they wished. They said the service was good at keeping them informed and involving them in decisions about their relatives care.

We have made a recommendation that the service reviews its bathing and showering facilities, considering the personal care needs of the people living there, in line with best practice.

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

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.

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.

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.

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.