We carried out an unannounced comprehensive inspection on 9 June 2018.

Two Trees Caring Home provides care and accommodation for up to 28 people with learning disabilities. On the day of our inspection there were 23 people living at the care home. In relation to Registering the Right Support we found this service was doing all the right things, ensuring choice and maximum control. Registering the Right Support (RRS) sets out CQC’s policy registration, variations to registration and inspecting services supporting people with a learning disability and/or autism.

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.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated good:

People were not all able to fully verbalise their views and staff used other methods of communication, for example pictures or visual choices. We met and spoke with 21 people during our visit and observed the interaction between them and the staff.

People remained safe at the service. People were protected from abuse as staff understood what action they needed to take if they suspected anyone was being abused, mistreated or neglected. Staff were recruited safely and checks carried out with the disclosure and barring service (DBS) ensured they were suitable to work with vulnerable adults. There were adequate numbers of staff to meet people’s needs and help to keep them safe.

People’s risks were assessed, monitored and managed by staff to help ensure they remained safe. Staff assessed and understood risks associated with people’s care and lifestyle. Risks were managed effectively to keep people safe whilst maintaining people’s rights and independence.

People had their medicines managed safely, and received their medicines in a way they chose and preferred. Staff undertook regular training and competency checks to test their knowledge and to help ensure their skills in relation to medicines were up to date and in line with best practice.

People were supported by staff who had received training to meet their needs effectively. Staff meetings, one to one supervision of staff practice, and appraisals of performance were undertaken. Staff completed the Care Certificate (a nationally recognised training course for staff new to care). Staff confirmed the Care Certificate training looked at and discussed the Equality and Diversity and the Human Right needs of people.

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's health was monitored by the staff and they had access to a variety of healthcare professionals. The registered manager worked closely with external health and social care professionals, to help ensure a coordinate approach to people’s care. Some people’s end of life wishes were documented and included information on people’s wishes when needed.

People’s care and support was based on legislation and best practice guidelines; helping to ensure the best outcomes for people. People’s legal rights were up held and consent to care was sought as much as possible. Care records were person centred and held full details on how people liked their needs to be met; taking into account people’s preferences and w

We carried out an unannounced comprehensive inspection of this service on 29 March 2016. After that inspection we received concerns in relation to how people’s one to one needs were being met and managed by staff, staff not receiving training and insufficient staff employed. The concerns went onto say that people were being provided personal care very early in the morning and against their wishes and taken out into the community when they were unwell. Also that people stayed in their rooms for long periods and people were not receiving their meals in a timely manner with long waits in between. The concerns received also stated that people’s charts, for example food and fluid charts, were not being completed, medicines were not always being signed for after administration and being administered too early. Other concerns raised said that people’s continence needs were not always being met; people had to purchase their own continence aids and people’s healthcare needs were not being met safely.

As a result we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Two Trees Caring Home our website at www.cqc.org.uk.

Two Trees Caring Home is registered to provide accommodation with personal care, for up to 28 people who have a learning disability and may also have physical disabilities.

On the day of the inspection there were 21 people living at the service.

The service had 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’. The registered manager is also the registered provider. 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.

Throughout the inspection there was a calm, friendly and homely atmosphere. People appeared relaxed and happy. We were supported throughout the inspection by two members of the management team.

We met and spoke with 16 people during our visit. People were not all able to fully verbalise their views and used other methods of communication, for example pictures and sign language. We therefore spent time observing people. One person when asked if they were happy at Two Trees said; “I like living here.” One staff member said; “It’s a lovely place to work in.”

People’s medicines were managed safely. Where errors had been found, action had been taken to reduce the risk of recurrence.

People’s individual risks were documented, monitored and managed well to ensure they remained safe. People had their continence needs managed and assessed by a continence nurse specialist.

People were supported to maintain safe health care through regular access to health and social care professionals, such as district nurses.

People’s needs were met by sufficient numbers of staff. People who required it had additional staffing. People were observed to have additional support at meal times with some people receiving one to one support. Rotas recorded sufficient staffing to meet these requirements. Staff were knowledgeable about people's needs and received training, for example manual handling training, to help keep people safe.

People's dietary needs were recorded and staff were aware of how to meet these needs safely. For example people whose health had deteriorated were encouraged to eat what they wanted and when they wanted and advice was taken from healthcare professionals. People who required them had food and fluid charts completed.

People’s care records held information about how people wished to be supported and what level of support was required to help keep them safe. Records were regularly updated to reflect people’s support needs; particularly for people who required

The inspection took place on 29 and 30 March 2016 and was unannounced.

Two Trees Caring Home provides care and accommodation for up to 28 people. On the day of the inspection 22 people lived within the home. Two Trees Caring Home provides care for people who have a learning disability and may also have physical disabilities.

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 2008 and associated Regulations about how the service is run.

On the day of our inspection there was a very calm, friendly and homely atmosphere. People were relaxed and happy. People’s relatives all spoke highly about the care and support Two Trees Caring Home provided. A relative comment read, ‘A friendly atmosphere where people are cared for in a very professional and personal manner’.

People and their loved ones were full of praise about the caring nature of the staff. Comments included, “My sister is met by care and compassion. Staff are like guardian angels”, “I feel blessed that the staff care so much. I see so much positive interaction” and “Staff are very caring and very patient. They go out of their way to help”.

Staff encouraged people to be independent and promoted people’s freedom. People moved freely around the building and its grounds as they chose.

Care records were comprehensive and written to a good standard. They contained detailed personalised information about how individuals wished to be supported. People’s individual method of communication was taken into account and respected. People’s risks were well managed, monitored and regularly reviewed to help keep people safe. People had choice and control over their lives and were supported to take part in a varied range of activities both inside the home and outside in the community. Activities were meaningful and reflected people’s interests and hobbies.

People had their medicines managed safely. People were supported to maintain good health through regular access to health and social care professionals, such as district nurses, behavioural advisors and speech and language therapists.

Staff put people at the heart of their work; they exhibited a kind and compassionate attitude towards people. Strong relationships had been developed and practice was person focused and not task led. Staff respected people’s individual needs around their privacy and dignity.

The service had an open door policy, relatives and friends were always welcomed and people were supported to maintain relationships with those who mattered to them. Staff were well supported through induction and on-going training. Staff were motivated and encouraged to enhance their skills. Individual development was promoted. A staff member said, ““I’m always being encouraged to progress and further my knowledge.”

People were supported by staff who had a strong understanding of how to keep them safe. Advice was sought to help safeguard people and respect their human rights. All staff had undertaken training on safeguarding adults from abuse, they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated. The manager had sought and acted on advice where they thought people’s freedom was being restricted.

Staff described the management as very supportive and approachable. Staff talked positively about their jobs. Comments included, “My jobs lovely, it’s not a chore, it’s very rewarding”, “I love my job, some days can be stressful, but when you get to make their day better, that’s enough for me”, “I get praised, a thank you as I go out the door, goes a long way” and “I hate it when I’m not here.

We carried out this inspection to check if the compliance action set at our inspection of 13 October 2013, in relation to concerns about the management of people’s finances, had been met. During this inspection we did not receive any information from people who used the service.

At this inspection because we only looked at people’s financial records, and some elements of their care records, we were unable to answer all of our five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

From the information we looked at we were able to make a judgement that Two Trees Caring Home was safe.

At our inspection of 13 October 2013 we found there was not an effective system in place to support people to manage their money, to ensure people were protected from the risk of financial abuse. When we checked three people’s money we found there were discrepancies between cash held by the home and the recorded balance for all three individuals. The provider had not sufficiently recorded why they held people’s money and who acted as appointee for individual people’s finances, where they did not have the capacity to manage their finances.

At this inspection we checked if improvements had been made to the systems the provider had in place to support people to manage their money. We found the system for holding and recording people’s monies had been changed and was more robust. When we checked the monies held by the home against the financial records for four people we found these to be correct.

We looked at the care plans for the same four people and found a section detailing their financial needs had been added. This section recorded the individual’s mental capacity to manage all, or some elements of their finances, the name of the appointee who acted on their behalf and what money they received. We found, in all the care plans we looked at, that this information had been added and was correct for each individual.

This meant that people who used the service were protected from the risk of financial abuse, because the provider had put effective systems in place to support them to manage their finances.

On the day of the inspection we met and spoke with ten of the twenty eight people who lived at the home. We were able to speak with three members of staff.

Everyone we spoke with was happy living in the home. The comments we received included “It is nice here…the food is lovely and the staff are nice,” “It is lovely, I am happy here…I can do what I like…I go shopping and I like to do my washing.” From observation of care we concluded people were all looked after well the staff worked professionally with people, and the team were well organised.

We judged there were satisfactory systems in place to protect people from the risk of abuse. However due to the complexity of the system to manage people’s finances we could not be assured there was not a risk of abuse and / or financial mismanagement of people’s finances.

The accommodation was well furnished, decorated and maintained. The home was very clean and there were no offensive odours.

On the day of the inspection there were satisfactory staff on duty. There was a suitable recruitment process in place to ensure people employed were deemed as suitable people to work with vulnerable people. Training provision was overall satisfactory.

The service had an adequate quality assurance system. Record systems regarding care planning, staff recruitment and training, and the general management of the home were satisfactory, although improvement was required to records regarding people’s finances.

People we spoke with told us about their activities and lifestyle at the home.

All of the people that lived in the home had significant though varied care needs. We saw that the service cared for people and supported everyone that lived at the home to have a good quality of life.

The staff delivered care that supported people’s human rights, privacy and dignity. For example we saw staff talking with people in a respectful manner and we saw support being offered with sensitivity and care. The people that lived at the home were routinely offered choice throughout their daily lives.

We saw and heard that people’s personal care and health care needs were met and supported by the service. We heard about people’s daily activities and about how people that lived in the home went out of the home to enjoy their community and had entertainments available in the home. People that used the service had a fulfilling and active lifestyle. People’s care planning and risk assessment were in place but we noted some minor issues in recording and risk assessment.

We walked around the home and saw that people had their rooms individualised to their needs and preferences. We saw that the building was being maintained and was clean and hygienic.

The staff that were employed by the provider were receiving training. This training helped staff to deliver good quality care, safely. The care staff were also receiving in formal and regular supervision to support their delivery of care.

We made two visits to Two Trees Caring Home as we had received information of concern. These concerns related to some people living in the home becoming aggressive towards other people living in the home, and some staff not being adequately trained to manage people who could become challenging.

We spoke with or met all 27 people who used the service, eight staff members and three visiting professionals. As some were unable to communicate with us we observed staff interaction with them. We also spoke with the registered manager.

We looked at the care records of six people who used services and considered aspects of their care and treatment.

Not all the files we looked at identified all the people’s needs and not all were completed accurately. This may mean that staff did not have the information they needed and people’s care needs may not be met.

One relative survey returned to the home said, “I am very pleased with everything at Two Trees”. One professional survey from a local G.P. said, “A well run caring home which feels like a large extended family”. One person who used services said, “Staff helps me”.

Some people felt at risk from other people in the home due to people either shouting at them or being aggressive.