Archived: Yew Tree Manor Nursing and Residential Care Home

People’s experience of using this service and what we found

People’s individual risks were not always assessed, monitored and managed effectively. Records of people’s dietary requirements, which placed some people at increased risk of choking or aspiration, had not been maintained accurately. Equipment to aid moving and handling of people was not managed safely.

There were numerous risks to people’s safety around the home. For example, there were a significant number of trip hazards and a fire exit was blocked. Health and safety records were in place and up to date.

Staff told us the home was often short staffed as staffing numbers had been reduced. This had a negative impact on people's care as staff did not have sufficient time to meet people's needs.

Staff training records were not up to date. It was, therefore, difficult to ascertain whether staff had completed the required training. Incidents were not always recorded and escalated as required.

Staff files were difficult to locate and information was kept in different places. However, the files included appropriate documentation to indicate staff had been recruited safely.

Medicines were not always managed safely. Medicines audits had not been completed for some time, so issues had not been identified and addressed. Thickeners, used when people required their drinks thickened due to choking risks, were not stored safely and were being used communally, for anyone who required them, rather than for the individual for whom they were specifically prescribed. There were no care plans in place for two people who had medicines administered covertly (hidden in food or drink). Senior care staff, who administered medicines, were only required to complete online training and their competence was not regularly re-assessed to ensure their skills continued to be of a good standard.

The premises were not clean, and basic infection control and prevention requirements were not being followed. There was a backlog of laundry and the laundry room had no system to separate clean and soiled items.

There was an appropriate safeguarding policy in place, which staff were aware of. Staff had completed safeguarding training at induction. It was difficult to ascertain whether concerns had been addressed appropriately, as records were not up to date.

People were not treated with dignity and respect. We observed some people waiting a long time to receive personal care. There were two shared rooms within the home. One in particular offered little privacy for the occupants, as it only had a small portable screen between the beds.

We saw little interaction between staff and people who used the service. Staff did not always have enough information to be able to support people well. There was little evidence to suggest people were asked for their views or involved in decision making around their care and support. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There were a number of incomplete or missing care plans and those that were in place had a lack of detail about people’s wishes and preferences. People told us they were not given choices with regard to meals. There was a lack of activities and stimulation within the home.

Although the nominated individual had visited the service in the months leading up to the inspection. They had not taken responsibility for supervising the management of the service or had any effective oversight.

Since the registered manager had left, there had been no system for dealing with correspondence. There were unopened appointment letters for people at the service, which could have had a detrimental effect on their health and well-being

There was no registered manager, deputy manager or clinical lead and no one taking leadership at the home. There was no management oversight, no audits or reviews, had been completed for a number of months. No one at the service had been taking responsibility for submitting notifications to CQC.

The service had not been working effectively with visiting professionals and this had put people at increased risk. This was due to the lack of management and leadership at the home. Complaints had not been monitored for some time.

Staff morale was low and there was currently little engagement from the provider with them. Staff we spoke with said they didn’t feel valued.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 30 April 2020). At this inspection we found the provider was in breach of regulations and the service was rated inadequate.

Why we inspected

The inspection was prompted in part due to concerns received from the local authority, around staffing and the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Yew Tree Manor Nursing and Residential Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment, staffing, person-centred care, consent, dignity and respect, premises and equipment and good governance at this inspection.

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.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

People’s experience of using this service and what we found

Staff respected people’s privacy and dignity and promoted independence, equality and diversity. There was no discrimination in the service. Most staff were patient, kind and friendly when attending to people, however, we did see some examples of poor practice and brought this to the manager’s attention. We have recommended staff undergo further training to ensure people receive fully person-centred care. People were reassured as they received support from staff who were familiar with their support needs. Staff demonstrated knowledge of people's personalities, individual needs and what was important to them. The service involved people and their relatives in the planning and delivery of care.

The home was without a registered manager at the time of this inspection, which is a condition of the provider’s registration with CQC. There was a manager in place who had taken steps to progress their application prior to this inspection. Staff told us they received better leadership and direction from the new manager; they felt part of a team. The service had more effective systems of quality assurance in place which assessed and monitored the quality of the service. The provider had implemented a number of key changes to the service to improve the quality of care. People living at Yew Tree Manor, their relatives, professionals and staff all considered management of the service had improved. The provider needs to sustain these improvements and ensure they are fully embedded into practice.

People told us they felt safe. Risks to people’s health and safety were now managed well. Stairgates had been installed to prevent access to stairwells and reduce potential accidents. People’s needs were met safely with appropriate staffing levels; the use of agency staff was minimal and consistent staff were used. People were supported by staff who understood how to identify and report potential abuse. The concerns we identified at the last inspection in relation to covert medicines had been fully addressed. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again. Checks were carried out on new staff to ensure they were suitable to work in the home. Infection control was managed well and an odour in one area of the home was addressed immediately on making the manager aware.

Care records indicated that people would receive effective care. There was evidence of monitoring and review of care, and the home worked in tandem with other health professionals to make sure people received the right care and support to maintain good health. Staff had handovers, regular meetings and had received supervision in line with company policy. Staff considered the training they received meant they could provide effective care and support. People’s specific dietary needs were communicated to staff employed in the kitchen, who were aware of recommendations made by health professionals. The manager was aware of their responsibilities in respect of consent and involving people as much as possible in day-to-day decisions. Where best interest decisions were necessary appropriate healthcare professionals and family members were involved.

Electronic care plans were person-centred and contained accurate information about people’s health conditions and wellbeing. Handovers ensured information was communicated to all staff to ensure people received safe support. There was a good range of activities and events going on in the home. People and their relatives were confident to raise issues and concerns. Complaints procedures were effective. The service sought feedback to help maintain and improve standards of care. People, relatives and professionals we spoke with were complimentary of the quality of care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 13 February 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two inspections.

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Yew Tree Manor Nursing and Residential Care Home on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Yew Tree Manor Nursing and Residential Care Home (Yew Tree Manor) 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. The home can accommodate up to 43 residents who require nursing or personal care and who are living with dementia and may lack mental capacity. At the time of our inspection there were 37 people living in the home.

We last inspected Yew Tree Manor on the 30 April and 1 May 2018. At that inspection, we found multiple breaches of regulations, the service was rated Inadequate and placed in special measures. Following this inspection, we met with the provider to confirm what they would do and by when to improve the key questions of safe, effective, caring, responsive and well led to at least good.

Following our inspection on the 30 April and 1 May 2018, we took enforcement action against the registered provider. This included serving a Notice of Proposal (NoP) to cancel the registration of the service. The provider put forward representations to the Commission (CQC) in respect of the NoP to cancel the registration of the service and the decision taken by CQC was to withdraw the NoP to cancel the registration of Yew Tree Manor.

At this inspection, we found a number of improvements and whilst we still identified some areas of concern in relation to medicines management and aspects of the premises safety, we were satisfied the home had made the necessary improvements to be removed from the special measures framework.

While we were on inspection we received a notification from HM Coroner. This was a Regulation 28 Report (Prevention of Future Death Reports) that was served against the provider. Coronial investigations or inquests are undertaken to determine the cause or manner of a person’s death. The coroner identified a number of failures at the time of this death in November 2017. Such as concerns around inadequate and insufficient care plans, failure to have appropriate daily observation records, to ensure full clinical records of any physical examination and action taken as a result being made, to ensure sufficient numbers of adequately trained staff at all times, to ensure agreed protocols for seeking specific medical help, to ensure adequate supervision and governance of all relevant staff and a failure to be able to demonstrate, even at the time of the inquest hearing, specifically what changes in practice and procedure had been made. At this inspection, we found the provider's response was satisfactory and the actions taken had been assessed as effective. The provider was also in the process of responding to the HM Coroner with their response to the concerns noted in the Regulation 28 Report.

There was a registered manager at 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. The registered manager was appointed shortly after our last inspection and was supported by a business manager. At the time of our inspection the registered manager was not available due to being on annual leave.

Although some aspects of the medicines systems had improved we found shortfalls in respect of the availability of guidance for medicines that are prescribed to be taken as and when required and in addition the management of medication expiry dates.

During our last inspection we found the laundry room had been left unlocked, the contents of this room which included equipment and chemicals could pose a hazard to people who lived at the service. We found this to be an issue again at this inspection. Furthermore, we had concerns about one of the stairwells not being restricted which at the time presented a possible falls risk. Shortly after the inspection the registered provider notified us that they had installed a stairgate to minimise the risk.

The registered manager was aware of their regulatory responsibilities. The registered manager notified CQC of events and incidents that occurred in the home in accordance with statutory requirements. However, we found one incident had not been report to CQC by the previous manager in September 2017 that was noted in the HM Coroner Regulation 28 report.

We have made a recommendation in respect of care planning. We found inconsistencies in the level of detail recorded in people’s care plans. Although we found this had not compromised people’s care, we found care plans needed to ensure they were person centred.

Staff received an induction programme and on-going training. Staff had attended a variety of training to ensure that they were able to provide care based on current practice when supporting people. They were also supported with regular supervisions and observed practice. We have made a recommendation that the provider reviews the health and safety and medication training to ensure all staff are fully aware and reminded of the significance of potential risks posed to the environment and the management of medicines.

During this inspection we found there were enough staff available to meet the needs of people living at the home.

Care workers were knowledgeable about safeguarding adults from abuse and knew what to do if they had any concerns and how to report them. Safeguarding training was provided to all staff.

The service was working within the principles of the Mental Capacity Act 2005. Mental capacity assessments had been completed to demonstrate people's ability to understand and consent to care.

People continued to be supported to maintain good health and we saw that people had access to their GP, district nurses and other specialist services.

The home employed two full time activity co-ordinators. People spoke positively about the activities on offer and told us they were looking forward to forthcoming trips out that the activity co-ordinators had arranged.

People's nutrition and hydration support needs were effectively managed. People were regularly assessed and measures were in place to monitor and mitigate risk. We found that appropriate referrals were made to external healthcare professionals and any guidance which was provided was incorporated within care plans.

We found the home to be clean, hygienic and odour free. Communal areas, toilets, bathrooms and bedrooms were well maintained. Infection prevention control measures were in place and staff had access to personnel protective equipment (PPE) such as gloves, aprons and sanitizing gels.

People told us that they were well cared for and in a kind manner. Staff knew the people they were supporting well and understood their requirements for care needs. We found that people were treated with dignity and respect. People were supported and involved in planning and making decisions about their care. We saw that where they were able to, people had been involved in the development of their care plans and had signed them to say that they had been consulted with.

We noted there were a number of quality audits in the service; these included medicines, care records and health and safety. Actions were identified following the audits. We saw plans were in place to improve the care records, training, recruitment of permanent staff, and to complete the re-decoration and maintenance work at the home. Although we found a number of audits in place and action plans devised, we found the provider needed to ensure audits around medicines, care plans and safety of the premises were much more thorough due to the shortfalls we found during this inspection.

Yew Tree Manor Nursing and Residential Care Home (Yew Tree Manor) 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. The home can accommodate up to 43 residents who require nursing or personal care and who are living with dementia. At the time of our inspection there were 35 people living in the home.

Since 2015, all comprehensive inspections of the service had found regulatory breaches. The last comprehensive inspection of this service was in September 2017 when two regulatory breaches were found for Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed. The service was rated as Requires Improvement overall, and rated good in caring.

At this inspection we found three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A serious incident had occurred at the home prior to our inspection. The Greater Manchester Police are investigating the incident. This matter is subject to an on-going investigation and as a result this inspection did not examine the specific circumstances of this incident.

The overall rating of the service is 'Inadequate' and the service is in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures."

The new manager had submitted an application to register with the Care Quality Commission. 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.

The management of medicines was not always safe and required improvement. Records indicated that medicines refrigerator storage temperatures were not always being monitored and recorded to ensure medicines remained effective and timely action had not been taken to rectify this. The competency of staff who had responsibility for the management and administration of medicines needed to be improved further. The provider did not have effective systems of assessing their staff team’s ability to manage and administer people’s medicines safely.

During a tour of the premises we found people who used the service were exposed to a risk of harm caused through the inappropriate storage of equipment, with the fire exit being blocked by a hoist and people’s bedroom doors being propped open. We noted the sluice room and laundry room had been left unlocked, the contents of these room which included equipment and chemicals. This posed risk of injury or harm to people living at the home.

We found that safe and appropriate recruitment and selection practices had not been carried out by management to satisfy themselves that only suitable staff were employed to care for vulnerable people. This was also the finding at the last inspection.

Whilst staff were observed to be kind and caring towards people, further work was needed to embed a culture of caring throughout the service. One person was seen to have their head in their hands most of the morning, but there was very little interaction or reassurance from staff who walked past. We provided feedback to the manager who informed us that staff were challenged if poor practice was observed by management.

Care plans had improved and provided more person centred information about the current needs, wishes and preferences of people. Risk assessments had also been updated to provide clearer information about identified areas of risk and how these were to be managed so that staff could quickly respond to people's changing needs.

Throughout the inspection, we observed examples of positive and caring interactions between staff and people who used the service. However, opportunities for such interactions were limited as staff primarily focused on the delivery of task based care.

We received mixed views from relatives about the quality of care their family member had received. Some relatives were satisfied, but other relatives shared concerns about the care their family member had received.

The service was not well led. Systems in place to monitor and improve the quality and safety of the service were not effective and this placed people at risk of harm. Some areas of service provision were not robustly monitored and effective action was not always taken in response to issues identified. Staff felt motivated by the new manager of the service and felt that improvements were being made.

We last inspected Yew Tree Manor Nursing and Residential Care Home on 24 and 26 January 2017 when we rated the home ‘Requires Improvement’ overall, with an inadequate rating for well-led. At that inspection we found breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, safeguarding service users from abuse and improper treatment, need for consent, and good governance. We issued two warning notices in relation to the need for consent and good governance to the provider to inform them of the reasons they were in breach of the regulations and to tell them improvements must be made.

Yew Tree Manor Nursing and Residential Care Home (Yew Tree Manor) is located in Northern Moor, south of Manchester. The home can accommodate up to 43 residents who require nursing or personal care and who are living with dementia. At the time of our inspection there were 34 people living in the home. The building is a large house which has been extended several times. Downstairs there are two large lounges and a smaller lounge which leads into the garden. There is a further lounge upstairs primarily for the use of families when visiting. Outside there are a garden and patio areas. There is a further two lounges upstairs primarily for the use of families when visiting and the other lounge was used as a quiet room for people to relax.

At this inspection we found improvements had been made in areas of concern, the issues raised in the warning notices had been addressed and the service was now compliant in those regulations However, we have identified one new breach in relation to the safe recruitment of staff and continued breach safe care and treatment.

At the time of the inspection, the service had a manager registered with the Care Quality Commission (CQC). 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.

Improvements had been made in the management of medicines, but further improvements still needed to be made to ensure all PRN protocols had been fully completed. We recommend the home reviews all PRN protocols in line with the latest guidance for managing medicines in care homes.

The provider did not have an effective recruitment and selection procedure in place and did not carry out relevant checks when they employed staff. This meant the systems in place did not adequately ensure staff’s suitability so that people were kept safe.

Staff had received appropriate training, supervision, and appraisals to support them in their roles. Staff, with the support of the management team identified their professional needs and development and took action to achieve them. However, we have made a recommendation because it was not clear how new staff were supported through the care certificate. This meant we could not be fully assured new staff had received a robust induction in health and social care.

Risk assessments were more thorough, and the risks people faced were captured. People’s known risks were discussed as on-going issues and staff communicated risk through meetings and handovers. Safeguarding practices were more robust and staff were confident in spotting and reporting issues.

The home was generally clean and tidy, although we found a malodour in the large lounge area of the home. The registered manager provided evidence that this area was regularly cleaned and the manager was looking at alternative ideas to eradicate this malodour from the home.

Care plans were based on the needs identified within the assessment; however there was some inconsistencies with the care planning process. For example, one care plan did not have a dementia specific care plan in place, a second care plan did not have a care plan in relation to the person’s diabetes care and a third care plan did not have a behavioural support plan to guide staff on their behaviours that may challenge others. Therefore the care plans did not reflect the current needs of these people.

Staffing levels were structured to meet the needs of the people who used the service. We found the atmosphere in the home to be calmer and more organised and the staffing structure was clearer.

There were improvements in consent documents and DoLS applications were now being made and followed up. People told us they enjoyed the food and relatives said there was choice on offer.

We saw caring interactions between staff and people. People were treated with dignity and staff knocked on doors and respected privacy where it was requested.

At the last inspection we found the home in breach of the regulation in relation to good governance as there were not effective systems in place to monitor the quality of the service. At this inspection we found the manager had established a key framework of responsibility and accountability. We found this process was an on-going process and we will continue to monitor its effectiveness at our next inspection.

The provider actively took part in the Manchester care home quality initiative pilot. This scheme headed by Manchester City Council was incorporated for a short period of time to review and assist homes in areas that they could improve on. Areas the quality initiative looked at were care planning, medicines management, infection control and safeguarding. Feedback from the Manchester contracts officer was that the home had actively engaged in this process, but there were still areas for improvement such as care planning and medicines management.

At the last inspection in January 2017, we found a number of potential safety hazards while we walked around the building. At this inspection we found those hazards had been rectified. However, we noted in one person’s bedroom they had an extension lead connected to another extension lead. We discussed this with the registered manager as this potentially posed as a fire risk. The registered manager confirmed shortly after the inspection this had now been addressed.

We saw people's access to activities had improved further and the home had recruited a new activities coordinator who was passionate about their role. People told us they enjoyed the activities on offer.

People using the service had access to a range of individualised and group activities and a choice of wholesome and nutritious meals. Records showed that people also had access to GPs, chiropodists and other health care professionals (subject to individual need).

A process was in place for managing complaints and the home's complaints procedure was displayed so that people had access to this information. People and relatives told us they would raise any concerns with the manager.

We found two 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.

Yew Tree Manor Nursing and Residential Care Home ('Yew Tree Manor') is located in Northern Moor, south of Manchester. The home can accommodate up to 43 residents who require nursing or personal care and who are living with dementia. At the date of our inspection there were 42 people living in the home. The building is a large house which has been extended several times. Downstairs there are two large lounges and a smaller lounge which leads into the garden. There is a further lounge upstairs primarily for the use of families when visiting.

At the comprehensive inspection of Yew Tree Manor on 3 and 4 May 2016 we identified seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (HSCA). The breaches related to the care and treatment of service users that did not always meet their needs, consent to care and treatment, premises safety, risk assessments not being completed accurately and systems and processes to investigate allegations of abuse were not always effective. We issued the provider with seven requirements stating they must take action to address these breaches. We shared our concerns with the local authority safeguarding team.

Following that inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to these breaches. This inspection was undertaken to check that they had followed their plan, and to confirm that they now met all of the legal requirements.

Additionally prior to the inspection the Commission had received a number of concerns. These related to recent safeguarding incidents at the home. Due to the seriousness of these safeguarding allegations we brought this inspection forward.

During this inspection we found that some improvements had been made. However, they were not sufficient enough to meet the requirements of the regulations.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'.

At this inspection we found people were not always protected from risks associated with their care because risk assessments were not always robust enough to provide guidance and direction to staff about how to keep people safe. People did not always have sufficient detail in their care plans to provide guidance and direction to staff about how to meet their needs.

We received mixed feedback regarding the leadership of the service. Visiting health care professionals felt the communication at the home was not always effective. However, the staff we spoke with felt supported by the management team.

The service had audit systems in place; however they had not been robust enough to identify the shortfalls found during this inspection.

The provider had made some improvements in regard to medicines. However, we found one person did not have PRN protocols in place. Furthermore, on the first day of our inspection we noted the morning administering medicines round took a number of hours to complete.

Potential safety hazards were identified by the inspection team as we walked around the building. We brought these concerns to the management team’s attention and found these had been resolved on the second day of our inspection.

Policies were in place to ensure people's rights under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were protected. Although policies and procedures were in place it was clear that they were not always put into practice. Staff and management did not have clear working knowledge of the current changes in legislation to protect people's rights and freedom. The provider was not following the principles of the MCA. It was not consistently and effectively followed to ensure people who lacked capacity to consent were provided with care that was in their best interests and in the least restrictive way. This meant the provider and the registered manager did not understand their responsibilities associated with the Act.

We found staff were recruited safely. Suitable checks were made to ensure people recruited were of good character and had appropriate experience and qualifications.

We reviewed the information and support available to ensure people received adequate nutrition and hydration. We found records were held as required to support people at risk of not receiving enough nutrition and hydration. We found advice given by specialist teams including GPs and dieticians was followed. Records in relation to monitoring people's intake of food and fluids were completed when required.

Staff had received appropriate training, supervision, and appraisals to support them in their roles. Staff, with the support of their line manager, identified their professional needs and development and took action to achieve them.

Procedures were in place to support people to access advocacy services should the need arise. However, we noted the provider had not supported one person who should have been referred to this service.

There was a system in place for reporting and responding to any complaints brought to the attention of the registered manager. However, we found one complaint could have been responded to better.

People were supported to maintain a healthy diet, and people's dietary needs and preferences were catered for. People told us they had a choice of food at the service, and that they enjoyed it.

Activities at the home were much improved since our last inspection. The service was looking to recruit a second activities coordinator.

The environment had some adaptations for people living with dementia.

Staff maintained people's dignity, and respected their privacy. Care records were kept confidentially.

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

The previous inspection took place on 20 and 24 August 2015. At that inspection we found breaches of seven regulations. The breaches related to staff numbers and support for staff, medicines management and the fire register, consent to care and treatment, dignity and respect, care planning, complaint handling, and governance.

We received an action plan on 26 January 2016 stating how the service had remedied or intended to remedy those breaches. We describe in this report whether and how improvements have been made to address those breaches. In our last report we gave the service the rating of Inadequate under the question “Is the service safe?” and Requires Improvement under the other questions, resulting in an overall rating of Requires Improvement. At this inspection two of the ratings have improved but the overall rating remains Requires Improvement.

Yew Tree Manor Nursing and Residential Care Home (‘Yew Tree Manor’) is located in Northern Moor, south of Manchester. The home can accommodate up to 43 residents. At the date of our inspection there were 39 people living in the home of whom five were temporarily in hospital. The building is a large house which has been extended several times. Downstairs there are two large lounges and a smaller lounge which leads into the garden. There is a further lounge upstairs primarily for the use of families when visiting. Bedrooms are on the ground and first floors. There are two lifts. Outside there are a garden and patio areas. The building is accessible to wheelchair users via a ramp and the home has disabled access facilities. Car parking spaces are available.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 in the home told us they felt safe. The physical environment was safer than at the last inspection. However, we had been contacted by two families who were unhappy about the level of safety in the home. In one case a vulnerable person had left the building unobserved due to a fire door alarm not working. We considered this was a breach of the Regulation relating to keeping people safe.

The other family had complained about many aspects of their loved one’s care, including the hygiene of their bedroom. At inspection we found the home was clean, with some areas for improvement, and the latest infection control report had given the home a high rating.

There was a range of risk assessments. One person was known to be susceptible to pressure ulcers. The relevant risk assessment was incomplete which meant that the risk had not been managed properly. This had contributed to a delay calling in the specialist nurses. This was a further breach of the Regulation concerning safety.

We saw some improvements in the storage and administration of medicines, compared with the previous inspection. Senior care workers were now involved in administering medicines, which gave the nurse on duty more time. We identified some areas for improvement in how medicines were given.

Some recording on the Medicine Administration Records was inaccurate. Since the last inspection some guidelines were in use for giving ‘as required’ medicines. However, we found several examples where these guidelines were not in use. We found this was a continuing breach of the Regulation relating to the safe management of medicines.

Staffing levels had improved and were now adequate. There had been a safeguarding incident when someone went to hospital over the Christmas period and there was no staff available to go with them. On a later occasion staff had accompanied the same person to hospital.

Recruitment processes were safe. Staff were trained in safeguarding and knew what to do if they witnessed or suspected abuse.

Some people told us they felt unsettled when objects went missing from their rooms, although in some cases they had been replaced by the home.

The building was well maintained. Problems with the fire register had been rectified.

We found that relatives had been allowed to sign consent forms on behalf of people who lacked capacity to consent to care and treatment. This was not in accordance with the Mental Capacity Act 2005. This was a continuing breach of the Regulation relating to consent. Mental capacity assessments were not being completed within the home. Applications under the Deprivation of Liberty Safeguards were being made.

Training and supervision of staff had improved since the last inspection.

The food was well liked and people’s dietary needs were met. People’s weight was monitored weekly or monthly. We found that one person’s weight had not been recorded as often as recommended by the Nursing Home Team. This was a further breach of the Regulation relating to keeping people safe.

Health professionals visited the home regularly. Improvements had been made in the environment for people living with dementia, following a recommendation in our last report.

Most people living in the home and their relatives expressed satisfaction with the care provided. We saw some examples of a caring and thoughtful approach by staff. We also saw some staff being impatient.

We noted that some people were untidy and unkempt. This matched information we had received prior to the inspection from a number of sources. We found this to be a breach of the Regulation relating to personal care.

Records were mostly kept secure and confidential, but we saw examples where they were left in public view. Where people were able, they were encouraged to be independent, and involved in their care plans. They could also take part in residents’ meetings.

We found that Yew Tree Manor was now more ready to care for people at the end of life instead of sending them to hospital. But there were examples where due to poor record keeping people had been sent to hospital despite an agreement that they would not be.

Care plans had improved and were thorough and well presented. There was a monthly review which enabled changes to be easily identified.

A new activities organiser had just been appointed. Some activities were offered but there was scope for the new activities organiser to engage more people in meaningful activities.

People knew how to make complaints. Recent complaints had been investigated and responded to appropriately.

We were aware of concerns that the home had not responded effectively to a serious allegation of abuse. The registered manager had not kept adequate records, although disciplinary measures had been taken. She minimised the seriousness of the allegation when talking with us. We found there had been a breach of the Regulation relating to safeguarding people.

The system of audits was more rigorous than it had been, including a new medication audit. Staff meetings and relatives’ meetings took place.

There had been criticisms made of the leadership of the home, but a deputy manager had recently been appointed who was working well alongside the registered manager.

In relation to the breaches found at this inspection, you can see what action we told the provider to take at the end of the full version of the report.

In May we found that the provider was not meeting the regulation concerning management of medicines. This was because photographs of people were not always present on Medicine Administration Records and on blister packs, creating a risk that medication might be given to the wrong person. We also found that medication was being given covertly to one person, without following the correct procedures. We now found that the provider had taken effective action in both these areas and was compliant with the regulation.

At the last inspection we found a number of errors of different kinds in care files. There was evidence of sporadic reviews and some documents which needed to be archived. At this inspection we saw evidence that the provider had devoted resources to improving the care files. The files we looked at were well-ordered and conducive to the delivery of safe and appropriate care.

We set out amongst other things to answer five key questions: "Is the service safe? Is the service caring? Is the service responsive? Is the service well-led? Is the service effective?"

The evidence that supports this summary can be found in our full report.

Is the service safe?

The people we spoke with told us they were secure and felt well looked after. People had a call button handset in their own bedroom and in communal areas so they could summon staff quickly if they needed help.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. There were no DoLS authorisations in place on the day of our visit.

There were appropriate arrangements in place to ensure people were kept safe within the building. Outside the building there was an enclosed garden and seating areas for people to enjoy in warm weather.

We found that many medication record sheets and blister packs of tablets did not have photographs attached. This meant there was an increased risk of medication being given to the wrong person.

We also found that poor record keeping in care files created risks.

Is the service caring?

People told us they were well looked after. One person said: "The staff look after me; I sleep well, there is good food and good company." We observed that although the staff were busy they had time to chat with people. We saw good practice in relation to moving people using a hoist.

We thought there was room for improvement in how the lunchtime was arranged, as it caused stress to both staff and people living in the home.

Is the service responsive?

The provider had a detailed and thorough system for inspecting and improving the quality of the service, and responded to events in a positive way. Both provider and registered manager responded well to issues we identified on the day.

Is the service well-led?

The registered manager was actively recruiting new nurses at the date of our visit. We considered that more support would help with maintaining better records. It might also free the manager's time to focus on aspects of leadership. The provider was active in providing scrutiny and guidance.

Is the service effective?

We saw that people were well-cared for, so the service was effectively fulfilling its main purpose. We found there were some areas for improvement, but felt that with the right support these could be achieved.

We observed care and saw that staff spoke with and supported people with dignity and respect. The provider was meeting all the outcomes we looked at on this inspection which were outcomes relating to consent, care and welfare, nutrition and hydration, sufficient staffing and complaints handling.