About the service: Tall Trees is a care home providing personal and nursing care for up to 60 people. On the day of our inspection there were 60 people using the service.

People’s experience of using this service:

People felt safe because of the quality of the care and support they experienced. There were enough staff. Staff were attentive to people's needs and responded quickly when people needed assistance. People knew how to raise any concerns about their safety.

Staff had received training in safeguarding and knew how to identify and report any concerns. Medicines were managed safely by staff who had been trained and assessed as competent to do so. The home was clean, odour free, with effective cleaning and infection control processes in place. Staff were recruited safely.

People liked the way the home was decorated. People could bring their own furniture and furnishings. Their rooms were decorated to their taste. We saw that the home was well-maintained.

People received effective care from a staff team who received appropriate training, ongoing supervision and support. An admission assessment had been completed for each person to ensure the home could meet their needs and for people were encouraged to discuss the care and supported they wanted. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. There were mixed but mostly positive opinions about the quality of meals provided. We found that people requiring a modified diet received it in line with professional guidance. Staff made sure people saw their GPs and other healthcare professionals when they needed to.

People and their relatives told us staff were kind, caring and treated them with dignity and respect. People had developed positive relationships with the staff, who had taken time to get to know people, their likes dislikes and interests. People and their relatives were encouraged and supported to express their views and were involved in the running of the home.

Staff supported people in a responsive way. Care plans were in place which explained how people wanted to be cared for. These were reviewed regularly to reflect people's changing needs and wishes. The home had an effective complaints procedure, which people were aware of, though very few had needed to use it. Where people had chosen to discuss their end of life wishes, these were captured. The number of activities offered to people dropped down after the activities co-ordinator reduced their hours. The manager was aware of the need for improvement in activities and was actively recruiting a new activities co-ordinator.

The home was well-led and managed. The service was led by a manager who was in the process of submitting their application to register with the Care Quality Commission (CQC). People, their relatives and staff spoke positively about the manager and the deputy manager who were reported to be friendly, approachable and willing to listen. A range of audits and quality monitoring were completed to ensure the standard of care was maintained and any issues identified and addressed. Action plans had been generated and completed to promote continuous employment.

The home met the characteristics for a rating of 'good' in all key questions.

Rating at last inspection: Good (published 28 April 2017).

Why we inspected: The inspection was a scheduled inspection based on the previous rating.

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

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

The inspection was carried out on 6 and 12 April 2017 and was unannounced. Tall Trees is a care home providing personal and nursing care for up to 60 people. On the day of our inspection there were 50 people using the service.

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 2008 and associated Regulations about how the service is run.

The service had benefitted from a stable management team who had ensured improvements were made following our inspection in February 2016. The registered manager promoted a person-centred culture and this was clear through all the interactions we saw during this inspection. There was a cheerful relaxed atmosphere throughout the inspection which demonstrated the positive relationships people had developed with staff. Staff were caring and attentive to people, valuing them as individuals.

Improvements had been made to ensure medicines were managed safely and people received their medicines as prescribed. There were sufficient staff to meet people's needs and staff were not rushed when supporting people.

People were supported by staff who understood their responsibilities to identify and report safeguarding concerns. The provider carried out appropriate recruitment checks to ensure staff were suitable to work with vulnerable people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible in line with the principles of the Mental Capacity Act 2005 (MCA). Staff supported people to be involved in decisions about their care and ensured people understood the choices available to them.

People enjoyed the food and received food and drink to meet their dietary needs. The atmosphere during mealtimes was relaxed and people were supported to eat and drink at their own pace. People were supported to access support from health professionals appropriately.

Staff were supported through regular supervision and appraisals. Staff were positive about the training they received and were supported to access vocational qualifications. Staff had confidence in the management of the service and felt the registered manager was supportive.

Care plans were personalised and gave clear guidance to staff about how people wished their needs to be met. Staff were knowledgeable about people's needs and saw people as individuals. People were supported to enjoy activities both in groups and individually.

There was a complaints policy and procedure in place and people felt confident to raise any concerns with the registered manager. There were effective systems in place to monitor and improve the service which included systems to seek feedback about the service.

We carried out our inspection on 16 February 2016. This was an unannounced inspection.

Tall Trees is a care home providing accommodation for people requiring personal and nursing care. The service supports older people with a variety of conditions which includes people living with dementia. At the time of our visit there were 47 people living in the service.

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. 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.

Everyone was extremely positive about the improvements made to the service since the arrival of the new manager. The manager was described as 'approachable' and people appreciated seeing the manager about the home. The manager promoted a caring culture that ensured people were at the centre of everything the service did.

Staff felt supported by the manager, however staff had not always received regular supervision. Staff had access to training to ensure their skills and knowledge were kept up to date.

We saw many kind and caring interactions throughout the day. There was a cheerful atmosphere with people and staff smiling and laughing together. Staff supported people with compassion, promoting independence and dignity. People and staff had developed meaningful relationships.

Staff were knowledgeable about people's needs and care plans provided information that ensured staff had clear guidance relating to the support people required.

Medicines were not always managed safely. People were at risk of not receiving their medicines as prescribed.

Where risks were identified in relation to people's physical needs care plans were in place to ensure risks were managed. Where there were risks in relation to people's anxiety and behaviour, care plans did not always contain risk assessments or guidance for staff in how to support people's behavioural needs.

Staff knew how to identify and report concerns relating to safeguarding vulnerable people. Staff were aware of the whistleblowing policy and felt confident to use it. There were enough staff to meet people's needs, however some staff were working excessive hours to ensure required staffing levels were achieved.

Where people were assessed as lacking capacity care plans did not reflect the principles of the Mental Capacity Act 2005 (MCA). Staff had not always completed training in the MCA. We have made a recommendation in relation to the MCA.

Systems to monitor the quality and safety of the service were not always effective. However most of the issues found during our inspection had been identified and were being addressed by the management team.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the end of the full version of the report.

This inspection took place on 22 January 2015. This inspection was unannounced which meant that the provider did not know we were completing an inspection on that day.

The previous inspection of this service was carried out on 17 April 2014. The service was found to be meeting all of the standards inspected at that time.

This location is registered to provide personal care and accommodation for up to 60 people. At the time of our inspection 49 people used the service. The service was divided into four units: Pine unit and Willow unit (units for people living with dementia); Oak unit and Beech unit.

At the time of our inspection the home did not have a registered manager. 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.

Staffing levels were not consistently maintained to ensure people received appropriate support to meet their needs. Staff told us that they were short staffed on some shifts, and where staff sickness occurred this had not been covered. The manager told us they were aware of this issue and were actively recruiting additional staff. However, additional staff had not been placed on shifts when staff were off sick.

Staff did not receive on-going supervision and appraisals to monitor their performance and development needs. The manager told us they had identified this issue and had put in place a supervision plan to ensure staff received regular supervision. People we spoke with told us they had no concerns about how staff provided care and support to them.

At lunchtime staff were available if people wanted support, extra food or drinks. Most people were satisfied with the choice of food available to them. Although several people told us they would like to see improvements in this area.

Staff were kind, caring and respectful to people when providing support and in their daily interactions with them.

Care plans did not demonstrate that people were involved in making decisions about their care. People told us there were not enough activities to take part in at the home and in the community. The manager told us they were aware of this and was actively recruiting activities co-ordinators to fulfil this role. People were supported and encouraged to maintain relationships with people who were important to them.

The provider regularly sought feedback from people who used the service. However, there was no evidence that the provider had taken action to improve the service quality in light of people’s feedback. The service had four consecutive managers in post in the past two years. Audit processes had not been consistently followed to drive service improvements.

Not all staff had received training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). This legislation sets out how to proceed when people do not have capacity and what guidelines must be followed to ensure people’s freedoms are not restricted. At the time of our inspection two DoLS applications were in place for people at the home.

Records showed that we, the Care Quality Commission (CQC), had been notified, as required by law, of all the incidents in the home that could affect the health, safety and welfare of people.

We found six 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 version of this report.

On the day of our visit there were 57 people using the service. Many of the people were living with dementia. They were supported by 16 care staff, administration, kitchen, cleaning, and hospitality staff and the manager.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

This is a summary of what we found;

Is the service safe?

We found that the service was safe. People told us they felt safe. One said "I am safe. I have no concerns what so ever about my safety". Another said "I am confident they will take care of me and keep me safe". Care workers were trained in safeguarding vulnerable adults and demonstrated a good knowledge of abuse, the risks of abuse and the signs abuse may be happening. They also knew how to raise any concerns appropriately.

People were assessed before admission to the home and their care plans reflected their needs. This meant people received safe and appropriate care.

Care workers were appropriately recruited, selected and trained and were physically and mentally able to do their job. The provider conducted background checks to ensure care workers were of good character, including references from previous employers. All care workers undertook a period of induction training to prepare them for their role.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. There was one active DoLs at the time of our visit. This had been correctly completed and a "best interest" assessment had been conducted. As the person had settled so well at the home an application to remove the DoLs have been submitted.

Is the service effective?

We found that the service was effective. People told us that they were happy with the care that had been delivered and their needs had been met. It was clear from our observations and from speaking with staff that they had a good understanding of the people’s care and support needs and that they knew them well.

People told us they felt respected and involved in their care. One said "I don't have any special needs and they try to get me to do as much for myself as I can. Yes I am involved". Another said "I'm involved, respected and my wishes are respected too". We spoke with six care workers and asked how they respected and involved people in their care, particularly those living with dementia. One said "I do try to involve them, for example with their mobility. I encourage them to move or walk if they can. I use different stimuli. Touch, speech, I show them and explain to them. Whatever works for the individual".

People's needs were effectively managed. For example we saw that people's tissue viability was monitored and preventative action taken to ensure skin integrity was maintained. We also saw that, where appropriate, specialist advice was sought and acted upon. For example, assessment by a Speech and language Therapist (SALT). We saw that recommendations were actioned to reduce the risk of a person choking.

Is the service caring?

We found that the service was caring. We spoke with four people and one relative and asked them about the service. One person said "the staff are hardworking and very friendly". Another said "excellent, I really like it here and I am well looked after". The relative said "the staff make this place, so friendly and helpful". Everyone we spoke with was very positive about the service. This showed us that people felt well cared for. We conducted a Short Observational framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed three people for 30 minutes in the lounge. One person was asleep and two were watching television. All three people were living with dementia. A care worker sat with them and encouraged and prompted conversation. The person asleep was left undisturbed. One person was able to respond verbally but the other had difficulties. The care worker used touch and signs to communicate with this person and offered them choices of drinks, biscuits and what programme to watch. Both people responded positively and the care worker involved them in the activity. This showed us that where people had difficulties they were still able to make choices and be involved in their care.

Is the service responsive?

We found that the service was responsive. People's diversity and religious needs were met. We saw that people who had stated they were religious were encouraged to attend services and activities. People's likes and dislikes were also catered for. For example, we saw that a group of people who liked gardening had spent the morning in the green house gardening. People's preferences were respected and we saw that where people had stated a wish to get up or go to bed at a certain time, this was recorded and complied with. People were able to attend regular meetings where they could raise issues or concerns such as activities or meal menu's.

Is the service well led?

We found that the service was well led. The provider recorded and investigated accidents and incidents. These were fed to a clinical manager who looked for patterns and trends before feeding back to the service with any conclusions or findings. We saw that learning from incidents resulted in a review of care to reduce the risks to people. Complaints were appropriately managed and the provider's policy on complaints was displayed around the home and contained in service user hand guides. Surveys were conducted and people's opinion were sought and acted upon. Care plans were regularly reviewed and we saw they were well maintained and up to date.