CQC report explained · a residential care home
What the CQC found at Yew Tree Holdings Limited
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Rated Good; inspectors found improved safety, effective care and leadership, but the building still needed refurbishment.
This was an unannounced focused inspection on 25 January and 1 February 2023. One inspector and an Expert by Experience spoke with 12 people, four relatives and seven staff. They also reviewed care, medicine, recruitment and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found better risk assessments, incident records, medicine management, recruitment checks and quality monitoring. People told inspectors they felt safe and well cared for.
People's needs were assessed and care plans gave staff clearer, personal guidance. Staff supported people's choices, food and healthcare needs. The home had enough staff, with a stable team and improved training and supervision.
The overall rating improved from Requires Improvement at the previous inspection in July 2021. The earlier breaches had been addressed. This was a focused inspection, so Caring and Responsive were not reviewed during this visit and their previous ratings were carried forward.
Improved risk management
Individual risks were assessed and staff had guidance on how to reduce harm. Accidents and incidents were reviewed so lessons could be shared.
“Processes were in place to make sure individual risks were identified and assessed.” from the report
Safer medicines
Medicines were stored, administered and recorded safely. Staff giving medicines had been trained and checked as competent.
“People's prescribed medicines were now administered and managed safely, in line with national guidance, including the ordering, storage and disposal of medicines.” from the report
Enough familiar staff
Inspectors found enough staff to meet people's needs. The stable team meant staff knew people well, with limited use of agency staff.
“There were sufficient staff to meet people's needs.” from the report
Good healthcare support
Staff contacted healthcare professionals promptly when people needed advice or treatment. Care plans were updated following professional advice.
“Staff contacted healthcare professionals in a timely way if they had concerns about people.” from the report
Stronger management checks
Audits covered medicines, care planning, infection control and health and safety. The manager followed up issues found through these checks.
“The provider's monitoring processes had improved so there was a more robust approach to checking the quality and safety of the service.” from the report
Building needs refurbishment
needs fixingSome parts of the home were tired and needed redecoration or refurbishment. An improvement plan was in place and work was due to start after the inspection.
“The premises were tired in places, in need of redecoration and some refurbishment.” from the report
Feedback had not been analysed
needs fixingThe latest survey results from people and relatives had not been analysed when inspectors visited. Staff survey results had also not yet been analysed.
“The latest survey with people and their relatives had been returned but had not been analysed at the time of the inspection.” from the report
- 01What refurbishment has been completed since the inspection, and what work is still planned?
- 02What did the latest survey of people and relatives show, and what action was taken after it was analysed?
- 03How do you make sure risk assessments and care plans stay up to date when someone's needs change?
- 04How are medicine audits checked, and what happens if a medicine record is incomplete?
- 05What were the previous ratings for Caring and Responsive, and when will these areas next be reviewed?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 25 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2021
Yew Tree Holdings Limited was rated Requires Improvement; inspectors found friendly care and enough staff, but important safety, consent, recruitment and record-keeping problems remained.
This was an unannounced focused inspection on 28 and 29 April 2021. Inspectors spoke with people, relatives and staff, reviewed care and medicine records, checked recruitment files and examined the home’s management systems.
The home was not always safe or effective. Risks were not always assessed or updated after incidents. Medicines were not always stored safely. Recruitment checks were incomplete. Some decisions about people who lacked capacity were not properly recorded or made in their best interests.
The home’s audits did not reliably find problems or lead to action. Care records did not always reflect people’s changing needs. The overall rating remained Requires Improvement, as did Safe, Effective and Well-led. Caring and Responsive were not assessed during this inspection, so their previous ratings were carried forward.
Enough staff
People and relatives said there were enough staff, and inspectors saw staff available throughout the home. Call bells were not left unanswered during the inspection.
“There were enough staff to support people safely.” from the report
Infection control
Inspectors were assured that the home used personal protective equipment, testing, cleaning and visiting arrangements in line with the guidance in place at the time.
“We were assured that the provider was using PPE effectively and safely.” from the report
Health and food support
People received medical attention when needed and were supported to eat and drink enough. People told inspectors the food was good and offered choices.
“People received the medical attention they needed if they had issues with their health and said the food was good and nutritious.” from the report
Open culture
People, relatives and staff said they could speak openly with the manager or staff and would be listened to. Staff meetings and feedback surveys were used.
“People and relatives told us they felt comfortable speaking to any member of staff or the registered manager if they had concerns or complaints and they would be listened to.” from the report
Medicine storage
seriousMedicine room and fridge temperatures were often above the recommended level, and no action was recorded. Audits had not identified or resolved this problem.
“Medicine room and fridge temperatures above the recommended guidance had not been identified through robust monitoring to ensure effective remedial action was taken.” from the report
Consent and DoLS
seriousCapacity assessments were not always clear or reviewed. Conditions attached to one person’s DoLS authorisation were not included in care plans and had not been met.
“One person had three conditions on their DoLS authorisation. None of these were referred to in their care plans and had not been met.” from the report
Overdue training
needs fixingSome staff had not completed refresher training on time. The manager had set deadlines, but further improvement was still needed.
“Some staff had not completed their refresher and update training in a timely way.” from the report
- 01How have you updated risk assessments and care plans after falls, incidents, behaviour changes or self-harm concerns?
- 02What action has been taken to keep medicine room and fridge temperatures within the recommended range, and how is this now checked?
- 03How do you make sure DoLS conditions are recorded in care plans and followed by every member of staff?
- 04What checks do you now complete on references, employment gaps and recruitment risk assessments before appointing staff?
- 05How many staff still have overdue refresher training, and how do you check that their skills remain safe and up to date?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not looked at and their previous ratings were carried forward. This explanation was written from the published report of 17 July 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Yew Tree Holdings Limited
4 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2014
Report published without a new overall rating.
- June 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 27 May 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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