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Archived: Yew Tree Care Centre Good

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating


Updated 18 June 2016

We carried out a comprehensive inspection of this service on 15 September and 27 October 2015. At this inspection breaches of legal requirements were found. There were insufficient staff deployed to meet the needs of people who used the service, the management of medicines was unsafe, Staff were not suitably trained and effective governance arrangement were not in place. The registered provider wrote to us telling us what action they would be taking in relation to the breaches.

We inspected Yew Tree Care Centre again on 5 May 2016. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting. This was another comprehensive inspection and also to check whether action had been taken in relation to the breaches identified at our inspection in September and October 2015. At our inspection on 5 May 2016 we found that the registered provider had followed their plan and improvements had been made in all areas.

Yew Tree Care Centre provides both personal and nursing care to a maximum number of 76 people. There are four separate units in the service. There are two units in which people living with a dementia are accommodated and cared for, one of which is for people who require nursing care. There is a residential unit in which people who require personal care are accommodated and cared for and there is also a general nursing unit. Units are divided across three floors. At the time of our inspection there were 71 people who used the service.

The home had a registered manager in place. 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 were sufficient numbers of staff on duty in order to meet the needs of people using the service. The registered provider had an effective recruitment and selection procedure in place and carried out robust checks when they employed staff.

We found that action had been taken to ensure staff completed all of the required training. Although not fully up to date the majority of staff (90 – 95%) had completed all of the mandatory training in health and safety, moving and handling, COSHH, fire and infection control and the nurses were undertaking sufficient training to meet the revalidation requirements. The registered manager was aware of the shortfalls in training and was arranging for this training to take place.

We saw that staff had received supervision on a regular basis and an annual appraisal.

Improvements had been made in the management of medicines to make sure people received their medicines safely, however further improvement was needed in the recording of medicines.

There were effective systems in place to monitor and improve the quality of the service provided. We saw there were a range of audits carried out by the registered manager. We saw where issues had been identified; action plans with agreed timescales were followed to address them promptly.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Staff we spoke with were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. However, fire drills including evacuation were out of date for many of the staff. The registered manager was aware of this and had been on training to carry out the fire drills with staff.

Risks to people’s safety had been assessed by staff and records of these assessments had been rev

Inspection areas



Updated 18 June 2016

Staff we spoke with could explain indicators of abuse and the action they would take to ensure people�s safety was maintained. This meant there were systems in place to protect people from the risk of harm and abuse.

People and relatives told us there were enough staff during the day and night to meet the needs of people who used the service. Robust recruitment procedures were in place to help ensure suitable staff were recruited and people were safe.

Appropriate arrangements were in place in relation to the recording the administration of oral medicines. There was a process in place for monitoring these records regularly to check that they were completed properly. However, records for medicines prescribed when required and the application of creams and ointments by care staff had improved but were still not fully completed.


Requires improvement

Updated 18 June 2016

The service was effective but improvement was needed.

The majority of staff had completed training which was considered to be mandatory by the registered provider. Staff had received training in challenging behaviour; however, this training had not equipped them with the necessary skills. Staff had received supervisions and an annual appraisal.

People had access to healthcare professionals and services. Where appropriate, people had mental capacity assessments; however, for some people they were not decision specific.

Staff encouraged and supported people at meal times; however some improvement was needed for the tea time experience for those people living with a dementia.



Updated 18 June 2016

The service was caring.

People were supported by caring staff who respected their privacy and dignity.

Staff knew the people they were caring for including their personal preferences and likes and dislikes.

People had access to advocacy services. This enabled others who to speak up on their behalf.



Updated 18 June 2016

The service was responsive.

There was a plentiful supply of activities and outings; however' some improvement was needed for those people living with a dementia who were less able.

People who used the service and relatives were involved in decisions about their care and support

People and relatives told us staff were approachable and they felt comfortable in speaking to staff if they felt the need to complain.



Updated 18 June 2016

The service was well led.

The service had a registered manager who understood the responsibilities of their role. Staff we spoke with told us the registered manager was approachable and they felt supported in their role.

People were asked for their views and their suggestions were acted upon.

Audits of the service were completed to assess and monitor the quality of the service provided.