During a routine inspection

This inspection took place on 5 June 2018 and was unannounced.

Green Trees is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Green Trees accommodates up to 16 people. On the day of the inspection, there were 14 people living at the home.

When we last inspected, we found breaches of legal requirements in relation to person centred care, assessing risks associated with people’s care, safeguarding people from abuse and not notifying CQC of important incidents.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good. At this inspection, we found that the provider had made improvements to address most of the concerns identified. However, we found that there was further improvement required to ensure people received care which met their emotional and social needs.

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.

We saw that improvements had been made to the provision of activities for people. However, we received feedback that on days when there were no activities, people were not stimulated. We also found provision had not been made to support people to access the community if that was something they wanted to do.

People told us they were well treated at the home and risks to their safety had been identified and ways to mitigate these risks had been recorded in people's care plans.

Staff were aware that the people they supported were vulnerable and they understood their responsibilities to keep people safe from potential abuse.

There were systems in place to ensure medicines were handled and stored securely and administered to people safely and appropriately.

The home maintained adequate staffing levels to support people.

We saw friendly, caring and supportive interactions between staff and people and staff knew the needs and preferences of the people using the service. Care plans were person centred and reviewed regularly.

People told us they enjoyed the food provided and that they were offered choices of what they might want to eat.

People had regular access to healthcare professionals such as doctors, dentists, chiropodists and opticians.

We saw evidence of staff induction and an on-going training programme. Staff had regular supervisions and annual appraisals. Staff were safely recruited with necessary pre-employment checks carried out.

Quality assurance processes were in place to monitor the quality of care delivered. Required statutory notifications had been submitted to CQC.

During a routine inspection

This inspection took place on 1 March 2017 and was unannounced. At our last inspection on 24 February 2015, the service was rated ‘Good’.

Green Trees Care Home provides accommodation and personal care for a maximum of 16 people. It is a family owned home for older people, some of whom may have dementia. On the day of the inspection, there were 15 people using the 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.

People were not always safeguarded from abuse and avoidable harm as the provider had not notified the local safeguarding authority of safeguarding concerns. The provider did not notify CQC of two known safeguarding concerns.

Although scheduled activities took place on some days, we found that people were sitting in the lounge with little interaction or stimulation. There were sufficient staff on duty to ensure people’s needs were met, however, we observed that people were left unsupervised for periods of time. There were a number of occasions during the inspection when staff did not interact with people.

Risks associated with people's care and support needs had been identified and these had been assessed, giving staff instructions and directions on how to safely manage those risks, However, we saw that people’s risk assessments were not always followed.

There was a complaints procedure in place and complaints were investigated. However, some people told us that they did not know how to complain.

Safe medicine management systems and process were in place to ensure that people received their medicines safely and as per their needs and requirements.

Care plans were detailed and person centred and updated regularly.

All staff had received training on the Mental Capacity Act (2005) and understood the importance of obtaining consent from people. Where people’s liberty was deprived, the appropriate authorisation had been applied for which was recorded on people’s care records.

People told us that staff were caring. People told us they could choose their own routines and staff supported them to maintain their privacy and dignity.

Mealtimes were relaxed and people were offered a choice with alternatives offered.

Safe recruitment and selection procedures were in place. Staff were supported with regular training and supervisions. Annual appraisals were not documented.

People were supported to access healthcare.

Quality assurance systems were in place to monitor the safety and quality of care provided. People, relatives and staff were invited to completer an annual satisfaction survey.

Staff and resident/relative meetings did not take place.

During a routine inspection

This inspection took place on 24 February 2015 and was unannounced.

At our last inspection in May 2014 the service was not meeting six of the standards we looked at. These were related to; maintain people’s autonomy and independence, planning and delivering care, protecting people from abuse, infection control, supporting staff and monitoring and assessing the quality of service provision. At this inspection we found that the service was now meeting all of these standards.

Green Trees Care Home provides accommodation and personal care for a maximum of 16 people. It is a family owned home for older people, some of whom may have dementia.

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 and associated Regulations about how the service is run.

People told us they felt safe at the home and safe with the staff who supported them. They told us that staff were patient, kind and respectful.

People and their relatives said they were satisfied with the numbers of staff and that they didn’t have to wait too long for assistance when they used the call bell.

The registered manager and staff at the home had identified and highlighted potential risks to people’s safety and had thought about and recorded how these risks could be reduced.

Staff understood the principles of the Mental Capacity Act 2005 (MCA) and told us they would presume a person could make their own decisions about their care and treatment in the first instance. They told us that if the person could not make certain decisions then they would have to think about what was in that person’s “best interests” which would involve asking people close to the person as well as other professionals.

People and their relatives said they had good access to healthcare professionals such as doctors, dentists, chiropodists and opticians.

Food looked and smelt appetising and staff were aware of any special diets people required either as a result of a clinical need or a cultural preference.

People told us they liked the staff who supported them and staff listened to them and respected their choices and decisions.

People using the service and their relatives were positive about the registered manager and management of the home. They confirmed that they were asked about the quality of the service and had made comments about this. People felt the management took their views into account in order to improve service delivery.

During a routine inspection

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive, and well-led ? Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and records we looked at.

Is the service caring?

People's needs were not always fully assessed and care and treatment was not always fully planned and delivered in line with their individual care plan. Planned activities were not available on a daily basis and there was no designated activities co-ordinator.

Is the service effective ?

Staff did not receive appropriate training, professional development, supervision and appraisal. There were no systems currently in place for regular supervision or appraisal of staff.

Is the service safe?

The provider had made suitable arrangements to ensure that equipment was properly maintained and suitable for its purpose. There were effective procedures in place for managing foreseeable emergencies. There were ineffective policies and procedures in place to protect people using the service from the risk of abuse, and from the risk and spread of infection.

Is the service responsive?

There were no formal systems in place to seek and learn from people�s experiences, comments and complaints. Staff did not receive appropriate training, professional development, supervision and appraisal.

Is the service well-led?

There were ineffective systems to regularly assess and monitor the quality of the services provided, and to identify, assess and manage risks relating to the health, welfare and safety of service users and others who may be at risk. There was no evidence to support monitoring review and amendments made to policies. A proactive approach to seeking feedback about the service was not in place and feedback had not been acted upon.

During a routine inspection

We spoke with five people who used the service and one relative. Their feedback indicated that people were satisfied with the care provided and they had been treated with respect and dignity. Their comments included the following, "they take good care of me," and "the staff are respectful and they talk nicely to me".

We observed that people were able to move freely in the home and they appeared well cared for. People who used the service and a relative stated that personal care needs had been attended to and they had access to healthcare services. Assessments, including risk assessments had been carried out. Care plans had been prepared and these were reviewed regularly. There were suitable arrangements for the administration of medication.

The premises were clean and people were satisfied with their accommodation. Essential maintenance had been carried out and there were regular Health & Safety checks. Fire safety arrangements were in place.

There were arrangements for quality assurance and audits. A recent satisfaction survey indicated that people who used the service and their representatives were satisfied with the services provided.

During a routine inspection

We spoke with two of the fourteen people who lived in the home. They were both happy living there and told us they were well cared for by staff. One person�s comments were typical when they said that the care provided was �pretty good�. Both people described the food provided as very good. A typical comment from a respondent to the provider�s annual satisfaction survey was, �Overall I give Green Trees 98% excellent. The home overall has a caring and very healing atmosphere�. Another person wrote, �A lovely residential home�.

We used the Short Observational Framework for Inspection (SOFI) during our visit. SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us. We observed the care and support provided to people and saw many examples of staff interacting sensitively and in a caring manner with people who used the service.

The provider worked in co-operation with other professionals to address people�s health needs and had taken reasonable steps to safeguard people from the risk of abuse. Record-keeping systems helped protect people from the risks of unsafe or inappropriate care and treatment.

During an inspection to make sure that the improvements required had been made

We spoke with people that use the service during our visit to the service.

We observed that the staff were checking on people in their bedrooms on the day of the inspection to ensure that support was provided to them.

People spoken to said they felt ��safe and were happy at the home��.

We observed the home was clean. We saw staff carrying out cleaning around the home.

A number of people when asked said they were happy with their bedrooms.

A person told us when asked about how staff had treated them ��The staff are kind; they do all they can to help ��.

During an inspection in response to concerns

We spoke with people who use services during our visit to the service. They were generally complimentary about the staff. Comments included, ��The staff are kind, not rude��. People also spoke positively about the care provided. One person told us for instance, about the service, ''They could be family, nothing to complain of at all''.

We asked people who use the service about how easily they can get staff attention when they want it. One person told us, "I say 'Would you mind?� and they answer me." Another person told us ��Staff do pop into my room, as much as they can.�� Most people who use services that we spoke to, said that they can get staff attention when they want it. However one person told us that the on-call buzzer in their room was out of sight and that she did not know how to use it.

People who use the service generally told us that they liked the food provided. Staff provided positive support to people over lunch.

The provider gave us copies of the Quality Assurance Questionnaires they had recently received from five healthcare professionals, and six people who use services and their representatives. The vast majority of the information indicated that people were satisfied with the personal care and support offered. People who use services and their representatives were satisfied with the food provided and the standard of the premises.