This was an unannounced inspection that took place on the 10 December 2018.

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 b

The first day of inspection took place on the night on 30 April 2018 and was unannounced. On 1 May 2018 an announced further day of inspection was completed. The inspection was prompted in part by notifications to us that raised concerns about people's care.

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

This inspection took place on 07 September 2017 and was unannounced, which meant the service did not know we were coming.

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 inconsis

This inspection took place over two days on 24 and 26 January 2017. The first day was unannounced, which meant the service did not know we were coming. The second day was by arrangement.

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 effectivel

This inspection took place over two days on 3 and 4 May 2016. The first day was unannounced, which meant the service did not know we were coming. The second day was by arrangement.

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 staf

The scope of this inspection was limited to following up on two regulations where we had found the provider non-compliant at the previous inspection on 9 May 2014.

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.

An inspector and an expert by experience carried out this inspection. We met the registered manager and one of the owners ('the provider'). We talked with four residents and five relatives who were visiting on the day of our inspection. We talked with other staff and we observed care being given. We also looked at care records and other files.

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 used a number of different methods to help us understand the experiences of people using the service. This was because some of the people using the service had dementia type illnesses which meant they were not able to tell us their experiences. We were able to speak with a small number of people who lived in the home. One of these people told us: "I find it good.... I can't fault it". Another person said: "They couldn't look after us better". All the people we spoke with were positive about the care they received.

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.

We used a number of different methods to help us understand the experiences of people

using the service, including observing care and speaking to those people who could give their views on the home. We were able to speak with seven people who lived in the home. They were all very happy with the care they received. One person told us: 'The staff do the best they can to help'. We briefly spoke with one relative of a person who lived in the home. They were generally happy with the care their relative received.

This inspection took place over two days on 20 and 24 August 2015. The first day was unannounced, which meant the service did not know we were coming. The second day was by arrangement.

The previous inspection took place on 15 October 2014, when we checked to see whether the service was now complying with regulations in two areas. We had found that the service was not complying with those areas at our inspection on 9 May 2014. On 15 October 2014 we found that the service was now meeting the regulations in those two areas.

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 34 residents. The building is a large house which has been extended several times. There are two large lounges and a smaller lounge which leads into the garden. Bedrooms are on the ground and first floors. There are two lifts (although one was out of action at the date of inspection). 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.

We found evidence that the numbers of staff on duty were not always sufficient. Although the registered manager told us that staffing levels had increased, in practice there were not always enough staff on duty to meet the needs of residents. Some residents complained that staff took too long to arrive when they pressed the buzzer, although response times were monitored. We found there was a breach of the Regulation relating to staffing levels.

We saw that appropriate checks were made before employing new staff. Disciplinary procedures were used when necessary but the records of these were incomplete. With the exception of newer recruits, staff were trained in safeguarding. The registered manager had reported safeguarding issues and attended a number of safeguarding investigation meetings.

We heard from a resident, and confirmed by observation that staff did not always check that medicines had been taken before signing the Medicine Administration Record. There was no guidance for when people should take ‘as required’ medication. We found that the systems for recording and storing and administering medicines were in need of improvement. This was a breach of the Regulation relating to the safe management of medicines.

The service had recently acted in response to adverse criticism by the fire service of its fire detection equipment. The fire register which was intended to assist firemen if they needed to evacuate people in an emergency was out of date. This was a breach of the Regulation relating to reducing the risks to people living in the home.

One of the two lifts had been out of service for about six weeks, which meant that some people had longer journeys to reach their bedrooms.

There was some paperwork in place to record that consent was given when necessary, but it was used inconsistently. This was a breach of the Regulation relating to providing care and treatment only with consent.

The registered manager was aware of the need to apply for Deprivation of Liberty Safeguards (DoLS) authorisations, and a number of applications had been made.

We saw from training records that the majority of staff were up to date with their training, but there were gaps and newer recruits had not yet received some essential training. Six established staff were not up to date with practical manual handling. The methods of providing supervision and appraisal for staff were also not adequate. This was a further breach of the Regulation about staffing, relating to enabling staff to carry out their duties properly.

The food was generally liked and the cook had a good understanding of how to meet people’s nutritional needs. The dining area was too cramped. Although some steps had been taken we observed there could be tension at mealtimes. There were some adaptations of the building for people living with dementia but more could be done. We have recommended that the provider consider and apply the latest guidance on providing a suitable environment for people living with dementia. The garden was a pleasant place to sit and was being well utilised on the days we visited.

We found evidence that action was not always taken promptly to deal with and treat health conditions. We also found that people’s basic personal care needs were not always being met. There was one person confined to bed who was unable to use the call buzzer and became distressed. We found this was a breach of the Regulation relating to treating people with dignity and respect.

We found evidence that Yew Tree Manor was not providing a good service for people at the end of their lives, and a higher proportion of people than in other comparable care homes were being transferred to hospital when they were nearing the end of life.

We found variations in care plans, but that in general they were of a poor quality and did not provide a basis for good person-centred care. Significant events had not been included in recent reviews of care plans. There was a breach of the Regulation relating to providing appropriate care that meets people’s needs.

There was an activities co-ordinator and some entertainments were provided for residents.

The system for recording and learning from complaints was not thorough. This was a breach of the Regulation relating to complaints.

The division of responsibility between the registered manager and the clinical lead was unclear. Some audits were carried out but they were lacking in rigour. Reviews carried out by the provider were lacking in detail and depth. This was a breach of the Regulation relating to effective quality monitoring of the service.

There was scope to obtain more feedback from residents and their relatives about the service. The staff meetings could also be used to hear staff’s ideas about improving the service.

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