Pear Tree Residential Care Home

Pear Tree Residential Care Home is a residential care home providing accommodation and personal care to up to 21 people. The service provides support to people living with dementia and older people. At the time of our inspection there were 18 people using the service.

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

Governance systems were not effective; systems and processes had failed to identify and improve the quality and safety of the service. The provider had failed to make improvements to ensure the home was well-led. The provider has been rated requires improvement within the key question well-led, at the previous six inspections.

The provider failed to seek and act on feedback from stakeholders. When feedback had been received through different process such as complaints, letters, and external concerns, the provider had failed to consider and use this information to improve the service for people.

Risks to people were not always effectively mitigated. Risks in relation to fire safety had not been addressed as fire doors were routinely wedged open and did not all fully close to protect people from the risk of fire. This had been raised to the provider by external agencies on two occasions, but no action had been taken to mitigate risks. Infection control processes were not robust. We observed poor practice in relation to the wearing and storage of PPE and the cleaning of the home.

People did not always receive person centred care. There was a lack of activities and engagement to meet people’s social needs and provide them with stimulation. People had made requests to improve their quality of life such as staff name badges to enable them to remember people names, but these had not been considered and acted on.

There was not always sufficient staff on shift, this included staff to provide activities and domestic duties. Staffing levels were not always provided in line with the numbers of staff required. The providers training matrix did not assure us that staff had received the required training to meet people’s needs.

We received mixed feedback about the quality of food. We have made a recommendation regarding this.

People told us they felt safe at the service and staff told us they were confident to report any allegations of abuse. Relatives were mainly positive about the support people received.

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. However, records of consent were not always in place. We have made a recommendation about this.

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 good (published 03 June 2021).

At our last inspection we recommended that provider seek advice about reviewing and updating their governance systems. At this inspection we found the provider had not made improvements in relation to their governance systems.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

Following a review of information held we identified concerns in relation to risk management and governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. During the inspection we identified concerns in relation to staff training, so we opened up the inspection to include the effective domain.

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 Good to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pear Tree 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 risk management, staffing, person centred care and 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

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Pear Tree Residential Care Home is a small care home that is registered to provide support to 11 older people, some of whom may be living with dementia. At the time of our inspection, nine people lived at the service.

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

Quality assurance systems had identified shortfalls but needed further development to ensure they continued to do so. We have made a recommendation about governance systems. Action plans had been created and completed to address quality issues.

Safeguarding concerns had been looked into and changes made to improve people’s safety. Staff followed individual risk assessments and took appropriate action to keep people safe. Staff ensured people lived in a clean environment. Infection prevention and control measures followed government guidance.

People received their medicines as prescribed and supported people in a person-centred way which maintained their dignity. There were enough staff to meet people’s needs safely and in a timely manner.

Staff worked closely with relevant professionals to ensure people’s healthcare needs were met. Staff were attentive and kind and people’s relatives were happy with the care provided.

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 Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last inspection was a targeted inspection therefore the service did not receive a rating (published 16 October 2019). This meant the provider kept the rating of good from the previous inspection (published 27 June 2019).

Why we inspected

We received concerns in relation to the care provided and safeguarding. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at 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.

The overall rating for the service has not changed and remains good. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Thorn Hall Residential Care Home is a small care home that is registered to provide support to 11 older people, some of whom may be living with dementia. At the time of our inspection, 11 people lived at the service.

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

The provider had reviewed and updated their systems to address shortfalls in their quality monitoring systems. Audit processes were more robust and allowed the registered manager and the provider to closely monitor the service. Issues were addressed, and appropriate plans were in place until problems could be fully resolved. People were happy with the service provided.

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 good (report published 27 June 2019). We rated well-led as requires improvement, as we found problems with the monitoring of the service.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 16 and 17 May 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this targeted inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Question Well-Led which contains those requirements.

The ratings from the previous comprehensive inspection for the Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed and remains good. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme for those services rated good. If we receive any concerning information we may inspect sooner.

Thorn Hall Residential Care Home is a small care home that is registered to provide support to 11 older people, some of whom may be living with dementia. At the time of our inspection, 11 people lived at the service.

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

Quality assurance systems had been implemented. However, audits were not completed regularly enough to identify and address problems in a timely manner. People were included in the development of the service and their preferences were taken into account.

People were happy with the care provided as staff were kind and caring. People said, “Staff are very nice and kind. I haven't found anything I dislike.” Staff respected people as individuals and supported people to maintain their independence. People told us staff maintained their privacy and dignity, though some care practices did not always promote this.

People trusted and felt safe with staff and there was enough staff to meet people’s needs. Recruitment, induction and ongoing training processes helped ensure only suitable staff were employed and that they had the required skills and knowledge. Staff were supported by the management team and received supervision and annual appraisals. People received their medicines as prescribed.

People enjoyed the quality and variety of the food and could help themselves to snacks and drinks. People were supported to access healthcare services and care plans were regularly updated to enable staff to meet people’s needs and provide person-centred 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. People could access a range of activities and spent their time as they chose.

People were happy with the management of the service. Complaints were addressed to people’s satisfaction and in line with the provider’s policy. Information was analysed to aid learning and to improve care.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 May 2018) and there were three breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, though the provider continued to be in breach of one regulation. This service has been rated requires improvement for the last three consecutive inspections but has now improved to good.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to the assessing, monitoring and addressing quality shortfalls at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Thorn Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is located in Thorngumbald, in the East Riding of Yorkshire. It has accommodation for a maximum of 19 older people, some of whom may be living with dementia. During this inspection there were seven people using the service.

The service had 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.

At our previous comprehensive inspection on 28 November 2016, the service was given an overall rating of requires improvement. Caring was rated as good. Safe, effective, responsive and well-led were rated as requires improvement. We issued two requirement notices for breaches in Regulation 17, good governance and Regulation 18, staffing. You can read the report from our last inspections on our website at www.cqc.org.uk. The provider completed an action plan to show what they would do to meet the requirements of the regulations.

Although we found some improvements had been made during this inspection visit, we identified continued breaches of Regulations 17 and 18, and an additional breach of Regulation 11, need for consent, of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. The providers systems for assessing and monitoring the service were not consistently identifying where improvements were needed. Staff had not completed the required training to ensure their skills and knowledge were up to date to carry out their role and meet people’s individual needs. Consent to care and treatment was not always sought in line with legislation and guidance. There was a lack of evidence that the Mental Capacity Act (MCA) legislation had been followed for two people.

This is the third time this service has been rated requires improvement.

Staff had been supported through the regular use of supervision. The service had a training matrix in place. We saw not all staff had been trained in control of substances hazardous to health (COSHH), nutrition, mental capacity act, equality and diversity, food hygiene, infection control and first aid. Staff files we reviewed showed five of those had no induction present.

Staff had developed good relationships with people using the service. Staff were aware of the importance of ensuring people's privacy and dignity was respected at all times, however we observed a number of occasions where they had failed to do this.

People lived in an environment that was suitable for their needs and checks on the services equipment were up-to-date. There was a programme of building work planned to change and improve the layout and facilities at the home. The environment was sufficiently hygienic however; the laundry room did not have any hand wash facilities. The provider told us there were plans in place to create a new laundry facility. We saw one bath had a part of enamel that had rubbed away and two toilet floor coverings had holes in them. This meant that any spills would be able to leak under the floor and would prevent the area from being cleaned effectively, increasing the risk of infection. Cleaning schedules had not been consistently completed. The registered manager updated us after this inspection with appropriate actions in response to these findings.

Staff had a good knowledge of what people could do, how they communicated and where they needed help and support. People were supported to make choices and decisions about how they spent their day.

Care plans were in place for each person who used the service. There had been improvements made to the information about people's individual preferences and how staff should provide person centred care.

People received good support to access health services when they needed them. The food in the home was good and people said they were happy with their diet. People enjoyed some group and individual activities.

Staffing levels were satisfactory and employees were subject to pre-employment checks before they were offered positions at the home. Risks to people in relation to their needs had been assessed. Staff were confident about how to protect people from harm and what they would do if they had any safeguarding concerns. The registered manager maintained records of accidents and incidents which gave them an overview of any trends.

People, their relatives and staff spoke positively about the registered manager and provider. Staff told us they felt supported. They described both the registered manager and provider as approachable and supportive. Any concerns or complaints were taken seriously, investigated and responded to.

You can see what action we told the provider to take at the back of the full version of the report.

At our last inspection of the service on 15 October 2015 the service was rated as ‘requires improvement’ and we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the premises and health and safety equipment within it were not safe for use or used in a safe way. We issued a requirement notice. As part of this inspection we checked if the registered provider had made improvements.

Thorn Hall in the village of Thorngumbald is a care home without nursing. It provides accommodation and care in single and shared rooms to 19 older people who may be living with dementia. There are communal lounges, a dining room, several bedrooms and bathroom and toilet facilities on the ground floor. There are also bedrooms and bathroom facilities on the upper floor, which is accessed by a stair lift. Grounds to the side of the house provide seating in the summer months. There is parking for eight cars. At the time of the inspection there were 13 people using the service, five of whom were living with dementia.

The registered provider is required to have a registered manager in post and on the day of the inspection the manager who was employed at the home was 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.

Recruitment was on-going to ensure enough care staff were employed to meet the needs of people who used the service. However, there was an expectation from the registered provider that care staff also filled the roles of activity person, cleaning and laundry staff and kitchen duties at tea-time. The staff team worked well together to ensure the needs of people were not affected by any dips in staffing levels and there was a good atmosphere in the service. We raised concerns with the registered manager about the impact the levels of staff were having on cleanliness of the service, activity levels and record keeping.

We found the staff training programme was not robust and did not include all necessary subjects to ensure that people who used the service were supported by staff with the right competencies and skills to meet their needs and keep them safe from harm. Although people who used the service and relatives told us they were satisfied with the quality and quantity of food and drinks being served, we found that the recording of nutritional needs and specialist diets could be better.

People knew how to make a complaint and those who spoke with us were happy with the way any issues they had raised had been dealt with. People had access to complaints forms if needed and the registered manager had investigated and responded to the complaints that had been received in the past year. However, these actions were not well documented.

We saw evidence that care plans were not always accurate or up to date. This meant that staff did not have access to complete and contemporaneous records in respect of each person who used the service, which potentially put people at risk of harm.

Quality assurance and record keeping within the service needed to improve. There was a lack of effective auditing within the service.

People who used the service told us that they received their medicines on time and were happy with the way they were administered by the staff. However, there were a few minor issues around record keeping that we discussed with the registered manager on the day of our inspection. These were considered by us to have a low impact on people who used the service. We have made a recommendation in the report about medicine management.

We found that the service was clean, tidy and free from malodours, but there were areas where infection prevention and control practices could be improved to demonstrate that staff were aware of hygiene and cross infection risks. We have made a recommendation in the report about infection prevention and control practices.

Some people who used the service were subject to a level of supervision and control that amounted to a deprivation of their liberty; the registered manager had completed a standard authorisation application for each person and these had been reviewed by the supervisory body of the local authority. This meant there were adequate systems in place to keep people safe and protect them from unlawful control or restraint.

People were able to talk to health care professionals about their care and treatment. People told us they could see a GP when they needed to and that they received care and treatment when necessary from external health care professionals such as the District Nursing Team or Diabetic Specialists.

People were included in decisions about their care and we saw that appropriate care and support was being offered to people who used the service. We observed a number of positive interactions between the staff and people they were caring for. Activities were low key and dependent on staff having time to carry these out. Although people said they would like these to be more varied and frequent no-one felt this was detrimental to their wellbeing.

We have found a breaches of Regulation 17 and Regulation 18 during this inspection in relation to good governance and staffing. You can see what action we told the registered provider to take at the back of the full version of this report.

We found that peoples' needs were met according to the information detailed in their care plans and risk assessments. People spoke well of the staff and we saw there were supportive relationships between people and staff. They said, "We are well looked after. The food is good", "The girls always help me" and "The staff are very good, they support me very well and their intentions are good'.

People told us they were happy with the arrangements to handle their medication. They said, 'The medication is managed by the staff, that's all right with me' and 'The girls give us our medication so we don't forget to take it'. We saw that systems to manage and administer medicines were safe.

We saw that while the environment was clean, homely and comfortable there were some areas that had not been upgraded for some years. The manager had personally been redecorating bedrooms and some new furniture and carpets had been purchased. The programme of upgrading was on hold at the time we visited.

We found that some areas of the service performance were audited and people were surveyed and although these had been analysed the information had not been collated to produce an overall performance statement as feedback to people and relatives.

Complaints were satisfactorily handled and resolved though there were no records to view for the last two years as no complaints had been made to the service. People said they knew how to complain and the procedure was clearly accessible.