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Inspection carried out on 25 October 2017

During a routine inspection

This unannounced comprehensive inspection took place on 25 October and 2 November 2017. We last inspected the service in November 2015 when we rated the service as Good overall, with two breaches of the Health and Social Care Act 2008 and Associated Regulations. The breaches related to staff practice not being in accordance with the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards. This was because some people who lacked capacity did not have their rights fully protected and had been subject to restrictions on their liberty for their safety and well-being without the proper processes being put in place. At this inspection we found that improvements had been made to staff training and understanding. The service now met the relevant requirements.

Treelands is a residential home registered to provide accommodation with personal care for up to 40 older people, some living with dementia. The service had 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 living at the service, their relatives and health and social care professionals gave us positive feedback about the service. One person said, “If all homes were like this one, there wouldn’t be anything to worry about.”

People said they felt safe living at the home. Staff knew how to identify signs of potential abuse, where and how to raise concerns and that these would be acted upon. Environmental risk assessments were undertaken but regular checks were not always undertaken. This left some people at risk of avoidable harm. Individual risk assessments were undertaken and records showed that appropriate measures had been put in place to minimise risks to people. Medicines were administered and stored safely.

An effective recruitment process made sure only suitable staff were employed to care for people.

There were sufficient numbers of staff on duty to support people. Staff received a thorough induction, training and ongoing supervision to enable them to carry out their roles. Staff felt well supported by management.

People were treated as individuals with dignity and respect and their consent was sought for care and treatment. Where people lacked capacity, the Mental Capacity Act 2005 and its code of practice was followed. Relatives, health care professionals and others were consulted and involved in best interest decision making. People received a varied diet in accordance with their own choices. People’s health needs were met by a range of external professionals. Healthcare professionals felt confident that the service delivered good quality service.

People and their relatives praised the staff for delivering high quality care. Staff were described as friendly, kind and caring.

People had individual risk assessments and care plans and had been consulted along with their families. There was a programme of activities on offer. Family and friends were able to visit freely and visitors were made welcome.

There was a variety of systems in place to monitor the quality of the service. Prompt action was taken to remedy any shortcomings. External organisations provided support to improve systems.

Inspection carried out on 17and18 November 2015

During a routine inspection

We carried out an unannounced inspection on 17 and 18 November 2015.

We last did a full inspection of the home in September 2013 and found a lack of leadership or clear responsibilities on some shifts. We inspected the home again in March 2014 to see if the provider had taken the necessary action and found effective improvement.

Treelands provides care and support for up to 40 older people, some of whom are physically frail or have been diagnosed with dementia. The home does not provide nursing care. People who live at the home access nursing care via the local community health services. There were 39 people using the service at the time of the inspection.

The service had 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.

Staff did not comply with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. This was not being done and had led to staff making unlawful decisions on other people’s behalf.

DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. The required steps to gain the legal authority to subject people to continuous supervision and control, including preventing them from leaving, were not always being taken.

People were supported by staff who were safely recruited to work with vulnerable adults. They were employed in sufficient numbers, trained, supervised and closely supported in their work.

People were protected from abuse and harm and risks to their health and welfare were assessed and managed.

People’s medicines were provided when and how they were needed.

People liked the food and they received a varied and nutritious diet. Dietary concerns were followed up.

Health care needs were met because staff contacted health care professionals in a timely manner and followed their expert advice.

Staff were considered kind and friendly. People and their family members said, “I’m happy here. The staff are all angels as far as I am concerned” and “The carers are perfect.” People were treated with respect, kindness and compassion.

Each person’s needs were assessed and planned. Care was delivered in a person centred way. This included the varied activities they were engaged in.. People’s physical, emotional, faith and social needs were met.

Complaints were investigated and used as a way to improve the service. One person said, “I am quite happy here, no complaints so far. The staff are very good.”

There was clear leadership from the registered manager and provider who were well known to people and their families. Staff said they were very well supported and the home was well-led. One said, “We know exactly what we are doing. It’s very well organised.” Regular monitoring checks, and listening to people’s views, ensured that standards at the home were under regular review.

Where improvement could be made it was and the home was well resourced to support any changes.

We found two breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.

Inspection carried out on 6 March 2014

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

When we (the Care Quality Commission) inspected Treelands on 8 and 16 September 2013 we found that the provider did not have effective quality assurance systems in place.

We found that there had not been leadership or clear responsibilities on some shifts. Some staff said that their views were not listened to and minutes of staff meetings did not provide evidence of any discussions or actions. We found that some incidents had not been analysed to identify learning and possible improvements.

We inspected Treelands again on 6 March 2014 to check that specific improvements had been made. We found that the provider had taken effective steps to improve the quality assurance systems at the home.

We found that there was a clear understanding of responsibilities and leadership. We saw evidence which showed that care workers' views about issues which could have an impact on quality were more clearly recorded and had been responded to.

Care workers told us about recent changes and new processes which had been introduced. Although some care workers felt that the pace of change was too quick, most staff we spoke with felt that the changes had improved the service.

We found that there had been proper analysis of incidents to support learning and improvement, especially in relation to medication.

Overall we found that quality assurance systems were more robust.

Inspection carried out on 8, 16 September 2013

During an inspection in response to concerns

This responsive inspection was as a result of concerns that were reported to us from two separate sources. We found that their specific concerns about qualifications held by staff, low staff numbers, a lack of respect for people and their choices were not substantiated by what we found during our inspection.

We spoke with nine members of staff, five people who used the service, and four relatives of people who used the service. People told us that care workers were "fine, no problem" and "fairly polite".

We found that Treelands had a clean environment which supported the delivery of safe care. We found that consistency in infection control was being monitored by the manager.

We looked at four people's care plans and found that they contained up to date needs assessments. Daily care records showed that people had been supported with their personal hygiene and individual health needs. Treelands had appropriate arrangements for protecting people from the risks of unsafe use or management of medications.

There were sufficient numbers of suitably qualified and experienced staff to meet people's needs at the time of our inspection visits. Plans to improve leadership on shifts had been made but not yet implemented.

We found that care workers were not always able to influence the service and that analysis of incidents did not always occur. This meant that the provider might not have had an informed view of the quality of the service.

Inspection carried out on 8 February 2013

During a routine inspection

At the time of our inspection 37 people were living at Treelands. There were eight care workers on duty, five ancillary staff and the manager.

An inspection in March 2012 had identified the need for improvements relating to the updating of policies, maintenance records and training. During this inspection we found that those improvements had been made.

People we spoke with told us that their care needs were well met. Comments included, "They help me as much as I want and do just what I need". We observed during our visit that call bells were answered promptly. People told us that food at the home was good and that there was enough of it. They told us that they felt safe. The home provided activities and people told us they were free to choose whether they took part in them. We observed that people were treated respectfully. People told us they were involved in decisions about their care.

Records showed that people's care needs were assessed and had been reviewed on a regular basis. Daily care records showed that care had been delivered in line with care plans. A district nurse who visited the home regularly told us that staff raised health concerns promptly. The home had measures in place to deal with emergencies.

Effective recruitment processes were in place and staff were supported with training and through regular supervisions.

The home had effective systems of quality monitoring in place and responded to feedback from people and their families.

Inspection carried out on 14 March 2012

During a routine inspection

We conducted an unannounced visit to Treelands Home Limited on 14 March 2012 as part of our programme of planned inspections. We were accompanied by an expert by experience. They are people, who, through their own experiences, are able to spend time talking to people who use the service about what it is like at the home. They spoke to 13 people and one visitor.

We looked closely at the care of one person, spoke to two care workers and the manager and two district nurses. We also looked at some records, policies and procedures.

People told us that they are able to make choices about their care and influence what they do at the home. One person said �Nobody forces you�. Another said "You get up at your leisure". We saw that staff asked people what they wanted and tried to accommodate their wishes. There were regular residents' meetings and a yearly survey of opinion, following which some improvement was implemented.

People told us about the health care services available to them, such as dentist, doctor, chiropodist and district nurse. People appeared to receive a high standard of personal care assistance and district nurses told us that staff follow their advice, produce good documentation, provide good end of life care and the home was always welcoming. They did, however, express concerns about staff training in the prevention of pressure sores. Other information supported this concern.

People told us about the activities available to them. This included a shop at the home, entertainment and arts and crafts. There was bingo the afternoon of the visit.

People gave good reports about the staff. Comments included �Can�t fault them� and �You can go to any of the staff if you have a problem�. Staff were adamant that they would not let abuse go unchallenged. However, they lacked some knowledge of how to do this, their training was due for renewal and policies on safeguarding adults were not readily available and were out of date.

We were told about the consistent staff team, some of whom had been at the home for many years. There were enough staff to meet people's care needs but not always with enough time to engage them in conversation. Whilst staff appeared competent, and people did not tell us they were not, there were several areas of staff training which were out of date or had not occurred where there was a need.

The manager was very proactive in ensuring that people who used the service, and all staff, had the opportunity to make their opinion known. However, she did not always have the time to manage other aspects of the home as she should, such as reviewing policies and procedures, which should inform staff how to do their work effectively.

Reports under our old system of regulation (including those from before CQC was created)