CQC report explained · a nursing home
What the CQC found at Yew Tree Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Requires Improvement; inspectors found risks from falls and medicines, and weak oversight of safety.
This was an unannounced focused inspection on 20 and 22 September 2022. Inspectors looked at Safe, Effective and Well-led. They spoke with people, relatives, staff and a visiting doctor, observed care and reviewed care, medicine and management records.
The home was not always keeping people safe. Falls risks were not consistently reduced, medicines were not always given as prescribed, and accident records were not analysed for patterns. Care plans and risk assessments did not always give staff enough guidance.
Inspectors also found that audits had failed to identify important problems. The home was rated Requires Improvement for Safe, Effective and Well-led. People and relatives said they felt safe and were happy with the care, and staff had access to training.
The overall rating changed from Good at the previous inspection, published on 24 January 2021. Caring and Responsive were not inspected during this visit, so their previous ratings were used in calculating the overall rating.
Safeguarding
Managers understood how to investigate and report safeguarding concerns. Staff knew how to recognise and report abuse.
“The registered manager understood their responsibilities to investigate and report any safeguarding concerns and worked well with other agencies to do so.” from the report
Staff training
Staff had induction training, refresher training systems and training they considered suitable for their roles.
“The provider had a system highlighting when staff required refresher training and what training staff had completed.” from the report
Infection control
Inspectors were assured about infection prevention, the use of protective equipment and the home's ability to manage outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe
People and relatives told inspectors they felt safe and were happy with the care and support.
“People and relatives told us that they felt safe with the care and support they received.” from the report
Falls risks
seriousKnown falls risks were not always managed effectively. Safety sensors were switched off during the day for one person who could enter other people's rooms, despite recent falls that included injury.
“However, steps had not been taken to effectively mitigate and reduce the risk of falls.” from the report
Medicine safety
seriousSome medicine records were not signed, instructions for as-needed medicines were not person-centred, and some tablets were crushed without suitable clinical guidance.
“Medicines were not always given in line with the prescribed instruction.” from the report
Learning from incidents
needs fixingAccidents and incidents were recorded but not analysed for causes, triggers or trends. This limited the home's ability to reduce repeat risks.
“There was no analysis of causes or triggers of incidents.” from the report
Care plans
needs fixingSome care plans and risk assessments were not updated or detailed enough to tell staff how to respond to changing needs. This led to staff managing risks inconsistently.
“The care plans for this person lacked detail and did not explain to staff what they should do, meaning staff were inconsistent in how they told us they managed the person's risks.” from the report
Management oversight
seriousThe home's audits did not identify several concerns found by inspectors, including medicine management problems. This was a breach of the governance regulation.
“The quality assurance procedures had not identified some of the concerns we highlighted during the inspection.” from the report
Staffing at some times
needs fixingInspectors saw one staff member supporting 11 people in a communal area while some people needed extra help to reduce falls risks. The manager said they would ask for more staff at that time.
“There were not always enough staff to ensure people received care and support when needed.” from the report
- 01What changes have you made to prevent falls, including when sensor mats and sensor beams are used?
- 02How do you check that medicines are given exactly as prescribed and that medicine records are signed?
- 03How do you make sure tablets are not crushed unless a doctor or pharmacist has confirmed this is safe?
- 04How are accidents and incidents now analysed for causes, triggers and repeated patterns?
- 05How do your current audits identify and correct problems with care plans, falls risks and medicines?
This was a focused inspection of Safe, Effective and Well-led, with infection prevention and control also checked under Safe; Caring and Responsive were not inspected and their previous ratings were carried over. This explanation was written from the published report of 18 October 2022 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, November 2021
Inspected but not rated; inspectors found mostly effective infection controls, but PPE practice was not always safe in the isolation unit.
This was an unannounced, targeted inspection on 2 November 2021. It looked at infection prevention and control during the COVID-19 pandemic.
Inspectors found that visitors were screened and tested, visiting arrangements followed guidance, and outbreak plans included an isolation unit. Staff testing and vaccination were also in place.
There was one concern about personal protective equipment. A staff member moved from a person's room into communal and kitchen areas without changing PPE. The home was not given a rating for this inspection.
Visitor screening
Visitors were screened for COVID-19 symptoms and had to complete a lateral flow test before visiting.
“On their arrival at the home, visitors were screened for symptoms of COVID-19 and were required to complete a lateral flow test to ensure their visit could take place safely in line with current guidance.” from the report
Supported visiting
The home arranged important visits for people receiving end of life care, including during an outbreak.
“However, for people who were receiving end of life care, important visits were arranged and supported safely.” from the report
Outbreak planning
The home had plans for an isolation unit and used the same staff group there to reduce the risk of infection spreading.
“This unit was staffed by the same staff cohort to limit the risk of cross contamination.” from the report
PPE was not always changed safely
seriousIn the isolation unit, a staff member moved from a person's room into communal and kitchen areas without removing and replacing PPE. Inspectors said this could put people at unnecessary risk.
“One staff member went from a person's room and into communal areas and kitchen areas without removing items of PPE, to replace with new PPE.” from the report
- 01What checks are now made to ensure staff change PPE when moving from the isolation unit to communal or kitchen areas?
- 02How do you manage visits during an outbreak, including visits for people receiving end of life care?
- 03How is the isolation unit staffed when there is an outbreak?
- 04How often are staff and residents tested, and how are the results used to manage infection risks?
- 05What action was taken after inspectors saw unsafe PPE practice?
This was an unannounced targeted inspection of infection prevention and control; the service was inspected but not rated and the report does not assess the other four key questions. This explanation was written from the published report of 26 November 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 Nursing Home
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- October 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Inspected but not ratedSafe: Inspected but not rated
- January 2020Goodup from Requires improvementSafe: Requires improvementEffective: GoodWell-led: Good
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 25 January 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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At least 100 live-in carers within about an hour of Worcestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.