At our last inspection on the 23 November 2016, we found the service was rated as ‘good’ under all the key questions. At this inspection we found there was improvement required under the key questions is the service safe and well led which meant the service is now rated as requires improvement overall.

The unannounced inspection took place on the 09 January 2019. Apple Tree Court provides accommodation and support for up to 26 adults. At the time of our inspection there were 17 people living at the 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.

There was 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.

There were insufficient numbers of staff available to meet people's support needs in a timely way. There were occasions when people were left unattended in communal areas. Staff had not observed one person enter another person’s bedroom on at least six occasions because there was no staff available to monitor the corridors. Staff did not have sufficient time to spend with people to engage in meaningful conversation or stimulating activities with some people telling us they were sometimes bored. You can see what action we have told the provider to take at the end of this report.

The home environment required improvement to ensure it was more ‘dementia friendly’ with appropriate signage and decoration to support people to navigate themselves around the home. The use of adapted cutlery, where appropriate, would enable people to eat independently. We have made a recommendation to the provider.

There were gaps in training that had not seen timely refresher sessions or courses being arranged for the affected staff. Some improvement was required to the monitoring of medicines to ensure the provider had appropriate processes in place to make sure people received their prescribed medication.

Staff understood how to protect people from risk of harm. People's risks were assessed, monitored and managed to reduce risk of avoidable harm. People were protected by safe recruitment procedures to ensure suitable staff were recruited. Staff understood their responsibilities in relation to hygiene and infection control.

People told us they received support from staff they felt had the skills required to support them safely. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. People were encouraged to eat healthily. People had access to healthcare professionals when needed in order to maintain their health and wellbeing.

Staff encouraged people's independence where practicably possible. People received a service that was caring and respected their privacy. People were supported by staff who knew them well.

People received a service that was responsive to their individual needs. Care plans were personalised and contained details about people's preferences. Processes were in place to respond to any issues or complaints. Where people’s faith was important to them, they were supported to continue with following their beliefs. This included their end of life (EOL) wishes.

The registered manager understood their role and responsibilities and staff felt supported and listened to. People and staff were encouraged to give feedback and their views were acted on to enhance the quality of the service provided to people. People and staff were complimentary about the leadership a

We carried out an unannounced comprehensive inspection of this service on 23 November 2016.

The home is registered to provide accommodation and personal care for adults who may have a dementia related illness. A maximum of 26 people can live at the home. There were 16 people living at home on the day of the inspection. There was 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.

At the last inspection on 9 and 10 September 2015, the provider needed to make improvements in managing people’s safety, management of medicines ,people supported with meaningful pastimes and stimulation and ensuring that identified areas for improvement where completed. We found that improvements had been made in medicine management, people being able to call staff and providing hobbies and interests for people.

People felt safe in the home and were supported in a safe way. Staff told us about how they kept people safe from the risk of potential abuse. During our inspection staff were available for people and were able to support them by offering guidance or care that reduced risks. People told us they received their medicines as prescribed and at the correct time. They also felt that if they needed extra pain relief or other medicines these were provided. People told us there were enough staff to support them when they needed or wanted help or assistance.

People told us staff knew how to look after them. Staff felt their training reflected the needs of people who lived at the home. People had been involved in the planning of their care and relatives felt they were involved in any decision making where appropriate. Where people had not been able to consent to certain aspects or decisions about their care records of decisions had been completed. People told us they enjoyed the food and that it was well prepared and were supported to eat and drink enough to keep them healthy. Where needed people were given assistance to eat their meal. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. People received supported to have their choices and decisions respected and staff were considerate. Staff anticipated people’s care needs and attended to people in a gentle and unhurried way. Staff developed positive, respectful relationships with people and were kind and caring in their approach.

Staff knew the care needs of people and people were involved in their care and treatment. Staff were clear about the expected care needs of people at the home. People and relatives we spoke with told us they happily raised any concerns or complaints with the management team.

People and relatives felt they were involved in the home and that it suited them well. The registered manager regularly checked that people and their family members were happy with their home and care provided. The management team were approachable and visible within the home which people and relatives liked.

During the last inspection of the service on 17 December 2013 we identified that the provider was not meeting the legal requirements associated with the Health and Social Care Act 2008. During this inspection we found that the provider had made some improvements to the standard of the service but needed to make further improvements to meet the legal requirements.

Min Y don provides residential care and support for up to 26 people who may have a diagnosis of dementia. At the time of our inspection there were seven people who lived at Min Y Don this is because the Local Authority had placed a suspension on new people residing at the home until improvements had been made to the quality of care provided.

At the time of the inspection there was a new manager in post who was in the process of applying to the Care Quality Commission to become the registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

People were supported in a safe way because detailed management plans were in place and staff understood the individual risks to people and how to support them safely. We found that people had their needs assessed and people’s preferences were taken into account which were clearly documented to provide guidance to staff.

We found that actions had been taken regarding the concerns raised at the last inspection about how medicines were administered. The new manager had improved the way that medicines were administered and managed. This meant that people received safer care and support in this area of their lives.

We found that improvements were needed to ensure that people who lacked capacity to make decisions were provided support in their best interests. Staff we spoke with were not aware of the provisions under the Mental Capacity Act (2005) to ensure that people were supported to make decisions about their care. The staff had not received sufficient training to help them follow the legal requirements of the Act. We found that people had not received mental capacity assessments and there were no care plans to show how to support people to make informed decisions.

Relatives we spoke with were happy with the care that was provided and told us that the staff were caring and compassionate. However we observed on two occasions that people’s dignity had not been considered by staff who had provided care on the day of the inspection.

There were recruitment procedures in place and staff had received the required recruitment checks that assured the staff were safe to provide people with care and support.

Complaints were handled and managed correctly and relatives told us that they were aware of how to complain if they needed to. Complaints were monitored by the manager which assured that actions that had been set were completed as required.

We saw that the provider undertook regular audits and assessed the quality of care that people who used the service received and acted upon any concerns. We found that the service was well led and the new manager was approachable to both staff and people who used the service. This meant that the service had taken action to improve the service to people.

We found that there were some breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full report.

We spoke with three people and observed how staff provided care to the eight people that lived at the home. We spoke with four staff and the provider, looked at care records for all the people living at the home which included three people’s care plans.

We found that people did not always have care plans in place that set out their care needs. This meant staff lacked access to appropriate guidance and there was a risk that people’s needs would not be met and their welfare and safety may be at risk.

We also found that people were not seeing dentists on a regular basis, which meant their dental health was potentially compromised.

We saw that staff were recording unexplained injuries but steps were still not taken to establish the causes of these injuries. The provider was aware of the action they should take if allegations of abuse were made and had referred allegations made to us at our last inspection to Wolverhampton City Council.

We saw that there were occasions where people did not have their medication as prescribed, and people with dementia were not routinely monitored to check if they may need pain relief.

One person told us, “Want anything ask and the staff they get it”. Another person told us there were enough staff and care was provided when needed. We found that there was sufficient staff numbers available during the inspection to allow people to receive support when requested/ required.

At the previous inspection in July 2013 we identified areas of concern in respect of the provider not identifying risks to people's safety and welfare. There were also areas of concern with how medicines were managed. We carried out this inspection to see what improvements had been made.

We spoke with four people out of 10 that lived at the home, two visitors, five staff, the acting manager and the provider during our inspection. We also looked at three people’s care records and three staff files.

We found that the home had made improvements so that people’s care was delivered in a way that was intended to ensure their safety and welfare. A visitor told us that when they spoke with other relatives, “They all seemed quite happy with how people were looked after”.

We saw that the provider had introduced methods for monitoring any injuries or bruises people sustained but was not monitoring this information and looking into whether findings from this monitoring indicated potential abuse. A relative told us that an allegation of abuse that had arisen, “Was all sorted out” appropriately.

We found that the service had made improvements in order to manage the risks associated with the unsafe use of medicines.

We saw that improvements had been made to ensure people were protected from the risks associated with the use of equipment.

We saw that staff that cared for people were subject to appropriate checks before they worked at the home.

We spoke with three people out of 11 that lived at the home, two visitors, five staff, a visiting professional, the acting manager and the provider during our inspection.

We looked at people’s care plans and saw that despite some updated information they did not reflect all of the specific health conditions people had. Staff we spoke with were not always knowledgeable about people’s needs and this resulted in care being provided in a way that was not always safe. One person told us that they had, “No complaints haven’t got any” and a visiting relative said, “More than happy with care”.

There were areas where the homes medication management needed to improve so that people were protected against the risks associated with medicines.

We saw that people were encouraged to eat their meals and were offered alternatives when they said they did not like what they were offered. We also saw that staff encouraged people’s fluid intake. Nutritional assessments were not robust enough to identify the level of risk to people of malnutrition.

People were not always protected from use of equipment as information about how it should be used was not always made available to staff.

We spoke with five people that lived at the home, one relative, a visiting healthcare professional, three staff, the manager and the provider during our inspection.

We saw a good rapport between people and staff. People were offered choices when provided with care. People said they received the care they wanted from staff. One person said, “Staff are great” and another that, “Good meals, I want and see fish on Fridays”. A relative commented in one of the home’s recent surveys that they were happy with the care their relative had. Staff were knowledgeable about people’s needs but there were still gaps in people’s care plans that did not reflect all that staff knew about people's needs. We saw one person was assisted to stand then walk inappropriately and there was inconsistency in their care plan as to how they should be helped to move safely.

There were areas where the homes medication management needed to improve so that people were protected against the risks associated with medicines.

Staff employed by the service were subject to appropriate checks prior to their employment. Staff told us they felt well supported by training and had on-going support from the management.

We saw that systems to assess the quality of the service were improving and the views of people and their relatives were sought more proactively. People's confidence in the service had improved although there was still scope to further develop the home’s quality monitoring.

We spoke with five people that lived at the home, five staff, the acting manager and the provider.

At our previous inspection in October 2012 we had concerns around how people’s care and welfare was promoted, how people were safeguarded, staffing levels and the systems the provider had in place to monitor the service.

During this inspection we found staff had a good rapport with people and gave them choices whilst providing care and support. We found the care and support people received matched their expectations. They told us, “I’m satisfied” and, “I can’t fault the staff”. A visitor told us that they had a response to concerns they raised.

People were more confident in the management and felt there was better access to the manager who responded to issues raised. The provider and manager had co-operated with social services to assist safeguarding investigations and followed their advice following these.

We found that staffing levels had improved and the number and dependency of people who lived at the home had decreased. We saw that staff were readily available to people and responded to requests for assistance promptly.

We found the provider still did not have an effective system for monitoring the quality of the service and protecting people from identifiable risks. Whilst we found the service had improved and people received better outcomes the lack of quality monitoring did not show how these improved outcomes would be maintained.

We spoke with three people and two visitors during our inspection. People’s dignity and privacy were respected and we saw occasions when staff engaged positively with people.

We saw that some people had limited stimulation. One person told us “There is nothing to do here”. A visiting relative told us that “People just sit in their chairs” with “no interaction with patients”.

We saw that people did not have care plans that reflected their specific health conditions. This meant information on people's health conditions and how they should be supported was not always available to staff. Staff did not always know about people’s individual needs. We saw occasions where people were supported inappropriately.

People told us that they were happy with the care that they received at the home. One person said they were pleased with the care, another that the staff were “Very nice and do their best” but “Not enough staff here to help you when you need it, not even when you want to go to the toilet you have to wait a long time”.

People told us they knew how to raise concerns about their safety but the provider had not always investigated allegations of abuse that had been raised to ensure people's safety.

The provider did not have effective systems in place that identified, assessed and managed risks to the health, safety and welfare of people who used the service and others.

Our inspection took place on 9 and 10 September 2015 and was unannounced. We last inspected the service on 25 April 2014 and found that the provider was not meeting the law in respect of ensuring people’s privacy, dignity and privacy were always considered when offered care. In addition the provider did not have suitable arrangements in place for obtaining or acting in accordance with people’s consent. After the inspection, the provider wrote to us and told us how they were going to make improvements to ensure these matters were addressed. During this inspection we found the provider had made improvements to the service in these areas.

Apple Tree Court is a care home that provides care and accommodation for up to 26 older people who may have dementia. There were 16 people living at the service at the time of our inspection.

The service had a registered manager at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe when supported by staff but two people said they felt temporarily unsafe on one occasion due to a specific occurrence. The registered manager has committed to addressing the reasons for this and did listen to people’s views. Staff, were however knowledgeable as to how to escalate any allegations of abuse and any incidents were escalated in accordance with local safeguarding procedures.

People told us they received their medicines when needed although systems for the management of medicines were not always robust enough to identify where people may not have received their medicines as prescribed, or that medicine records were always accurate. Other risks to people’s individual health and safety were assessed and we saw action was taken by staff to minimise risks.

People told us that they were sufficient staff available to meet their needs. People told us, and we saw care and support was provided in a way that showed staff were caring. Staff were knowledgeable about people’s care and support needs, and were supported with appropriate training.

People told us there were supported by staff to make decisions about their day to day care and staff understood how to promote people’s rights and work in their best interests. People’s healthcare needs were promoted and regular appointments with healthcare professionals were maintained.

People told us they enjoyed the choice of foods that were available and had enough to drink.

People told us that they felt well cared for and said staff understood what was important to them. They told us the way care and support was provided reflected their individual wishes. Staff had a good knowledge of what was important for people.

People had access to some planned activities and we saw staff tried to engage with and stimulate people. Some people however felt they could be better supported with meaningful pastimes and stimulation.

People knew who to speak with if they had any concerns and felt staff listened to them.

The provider had systems for gaining people’s views and monitoring the quality of the service. However, there was still scope to improve the service that was recognised by the provider and registered manager, and they told us they were committed to developing systems to ensure there was improvement. People told us they were happy with the quality of the service they received and told us were able to share their views about the service with staff.