Archived: Yew Tree Care Centre

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 reviewed. Risk assessments had been personalised to each individual and covered areas such as moving and handling, choking, falls and behaviour that challenged. This enabled staff to have the guidance they needed to help people to remain safe.

Staff had been trained and had the skills and knowledge to provide support to the people they cared for. Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions. Where appropriate there was evidence of mental capacity assessments, however, for some people these were not decision specific.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful, patient and interacted well with people. Observation of the staff showed that they knew the people very well and could anticipate their needs. People told us that they were happy and felt very well cared for.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People were weighed and nutritional screening had taken place.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

We saw people’s care plans were written in a way to describe their care, and support needs. These were regularly evaluated, reviewed and updated. We saw evidence to demonstrate that people and relatives were involved in all aspects of their care plans.

The service employed two activity co-ordinators to plan activities and outings for people who used the service. There was a plentiful supply of activities and outings, however more thought needed to be given to those people who were living with a dementia and were less able.

We saw a copy of the provider’s complaints policy and procedure and saw that complaints had been fully investigated with a written response to the complainant.

As part of this inspection we spoke with 12 people who used the service, six visitors, the regional director, the clinical lead, two nurses, five senior care staff, nine care staff and two domestic staff. We also reviewed records relating to the management of the home which included nine people's care records, staff rotas, outcome 16 review records, infection control audits, a range of other audits and staff training records.

We spent time in home observing how people's care was delivered during the early hours of the morning through to the afternoon.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. People were cared for in an environment that was safe, clean and hygienic. There were enough staff on duty during the day to meet the needs of the people living at the home. A minimum of ten staff were on duty overnight but frequently this was eleven and the provider added additional staff when people's needs changed.

People told us, 'There are plenty of staff around and they are all very kind and caring', 'I find that when I need a hand staff are always there and very willing to help' and 'We always find the staff to be competent, caring and very helpful. My relative never has to wait long and the staff seem to be on the ball so appear when needed.'

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. A large proportion of the people who used the service were living with dementia and this could impact their capacity to make decisions. Staff had started to look at what actions they needed to take to meet the needs of those who did lack capacity. We saw that Deprivation of Liberty Safeguard (DoLS) authorisations had been applied for and renewed when appropriate. Also staff were recording 'best interest' decisions and taking the necessary action such as involving the multi-disciplinary team in decisions around the covert use of medication. However, staff did not have templates to assist them identify what actions needed to be taken or to make sure they followed all the necessary steps. The provider sent us the documentation they had developed to address this matter and confirmed that these would be supplied to the home.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. We found that activities were organised within the home, but more consideration needed to be given to ensuring people who experienced dementia were offered meaningful activities and had items on their units that they could use independently such as books, games, items in 'rummage' bins and tactile stimulus.

People told us. 'The staff are kind, considerate and compassionate', 'The new manager is extremely approachable and has made sure all of the staff practice is aimed at making people's lives better', 'Overall the service is good but the activities need to be spread more fairly, as these seem to mostly occur on the residential unit. Today an entertainer is coming in but rather than doing a stint up here everyone has to go downstairs. My relative doesn't like change so won't go and just sits here.'

Staff had received training to meet the needs of the people living at the home. The provider had identified in their outcome 16 reviews that staff providing care for people who were living with dementia required more training around dealing with behaviour that challenges. The regional director outlined the training they were going to provide.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this.

We saw a vegetable garden had been created and that some of the people went out each day to attend to their vegetables. One person showed us some of the produce he had grown and was very pleased with how well it had grown.

Is the service responsive?

People's needs had been assessed before they moved into the home, however staff needed to become more adept at assessing potential risk people posed towards others prior to admission. Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. Staff would benefit from training around risk assessing aggression and recognising when they needed to inform the manager of incidents when staff had been assaulted.

Is the service well-led?

Staff had a good understanding of the ethos of the home and we saw that the manager had effective quality assurance processes in place. People told us they were asked for their feedback on the service they received. Staff told us they were clear about their roles and responsibilities. They said the manager consulted with them before implementing changes and their views were taken into consideration.

We completed this inspection to see if compliance actions had been met. We also checked that people were receiving appropriate care and received adequate nutrition. We announced the inspection date so visitors had the opportunity to speak with us.

We spoke with eight people who used the service and 14 relatives at the time and received correspondence from three relatives of people who used the service. We observed care practices on all floors. We met with the regional director and on the following day, the Chief Executive of the company and discussed what action was being taken to make sure the home delivered safe and effective care to people.

The people, relatives and staff we spoke with openly discussed recent problems at the home but all felt things were improving. All, including the provider, acknowledged that there had been significant problems at the home but were confident that action was being taken to resolve them. People said; 'The staff are good but there have been problems around getting a good management system in place. This does seem to be on the up now and the new manager is very good' and 'I have been very concerned but must admit the new manager and regional director have been really working hard to sort out these out'.

During this visit we checked all of the areas that the concerns had been raised about and determined if there was non-compliance with the Health and Social Care Act 2008 regulations. We commenced the inspection in the early hours of the morning and completed the visit in the late afternoon.

We spoke with 17 of the 62 people who used the service and nine relatives. We observed care practices on all floors. We met with the Chief Executive of the company and discussed what action was being taken to make sure the home delivered safe and effective care to people. We analysed the information about concerns that had been raised and looked at what action had been taken to investigate the issues and improve staff practices.

The majority of people who used the service, relatives and staff we spoke with openly discussed recent problems at the home but felt things had improved. People told us; 'I know there has been problems but it has not affected us' and 'I had a few niggles and mentioned these. They have been put right'.

People told us; 'It is first class, the staff always go that extra mile' and 'I am very happy here and think the staff do a really good job'. Other people told us; 'The staff on my relatives unit are exceptionally kind people and really do care', 'On the whole the staff seem to really want to provide the best care possible' and 'Staff make you feel important as a part of one big family.'

A proportion of the people who used the service experienced difficulty communicating their needs so we observed staff practices. We visited all six units and found that on every unit people looked comfortable, they were well groomed and consistently offered food and fluid on a regular basis. We found staff dealt with any personal care issues in a sensitive and discreet manner.

People told us; 'I am very pleased with the care I get, I am really happy to be here', 'It's lovely here, the girls are so nice, if I decide to have a shower they do help me, you don't feel that you are putting them out.' Other people told us; 'They are extremely kind people; they don't talk down to you', 'The care I get here is far better than the care I got in the other place I was in, here they listen to you and help you get things you want, I would not want to go anywhere else.' We were also told; 'Staff here are more like friends, they are wonderful.'

Although a large number of people are able to make choices, the nature of the service means some individuals may lack the capacity to make decisions. Therefore we checked whether the staff applied the requirements of the Mental Capacity Act 2005. We found that the staff had completed training and the provider had developed appropriate templates for staff to use, however these had not been completed.

We also found that overnight there were insufficient staff on duty to meet people's needs and the system for monitoring service delivery was not effective.

We found that staffing levels had increased again as the provider found people needed more assistance. Also an apprentice was working supernumerary on the nursing unit, which meant staff could spend more time ensuring people led fulfilling lives. The deputy manager also told us that another two apprentices were to commence work at the home.

We spoke with two people and three relatives and they were very positive about the service being provided at the home. The relatives told us that they found the staffing levels were good and staff ensured individuals were well cared for and safe. We observed that staff were visible throughout the home and at hand to support people as needed. We did note that dependency levels on the ground floor had increased. The deputy manager told us that they would review people's needs on this unit; ensure individuals were appropriately placed; and ensure that sufficient staff were on duty.